Depression: When a Member of the Flock Needs Special Care - Lesson 1
Depression is a common and serious illness that affects people in many different ways. In this lecture, you will learn about the causes, symptoms, and treatment of depression. The instructor discusses the importance of understanding depression in order to provide proper care for those who suffer from it. You will learn about the different types of depression, including major depressive disorder, persistent depressive disorder, and bipolar disorder. The lecture also covers the various treatments available, such as medication, psychotherapy, and alternative therapies.
A. Definition of Depression
B. Prevalence of Depression
C. Myths About Depression
II. Causes of Depression
A. Biological Factors
B. Psychological Factors
C. Environmental Factors
III. Symptoms of Depression
A. Emotional Symptoms
B. Physical Symptoms
C. Behavioral Symptoms
IV. Types of Depression
A. Major Depressive Disorder
B. Persistent Depressive Disorder
C. Bipolar Disorder
D. Postpartum Depression
V. Treatment of Depression
C. Alternative Treatments
VI. Supporting Those with Depression
A. Understanding the Experience of Depression
B. Communicating Effectively
C. Providing Practical Support
A. Summary of Key Points
B. Importance of Seeking Help
C. Hope and Recovery
- In the first lecture of the course "Depression: When a Member of the Flock Needs Special Care," you will gain insight into what depression is, how it affects people, and what causes it, as well as learn about the difference between depression and normal sadness, and how to recognize signs of depression.
- This lesson teaches you to view depression as a warning sign, and helps you understand the various causes and risk factors, including predisposing biological factors and neurotransmitters, for a more balanced approach to addressing and managing depression.
- In this lesson, you learn about the spiritual aspects that influence our understanding of the heart of God, examining misconceptions and stereotypes, as well as how depression affects Christians. Through biblical examples, you gain insight into God's compassionate response to those who struggle and his desire for a relationship with his followers.
- In this lesson, you learn about the complex nature of depression and the need for a balanced approach to treatment, considering spiritual, physical, and emotional aspects while debunking misconceptions about mental illness and prayer.
- In this lesson you will discover the importance of adjusting the focus of our thought life as part of the process of overcoming depression. You will also learn about the importance of having an open discussion about depression in the context of a church community. And finally, two common mistakes we make often make; trying to control things we don’t have control over and not controlling things we do have control over.
- In this lesson you will learn about the importance of dealing with anger appropriately and hear suggested strategies for doing it. This lesson also covers the importance of an accurate self-concept and how scripture informs us in this area.
The primary subject of this course is depression. In much of the Christian world this topic has been taboo, misunderstood and rejected out of hand. If that is your perspective, let me encourage you to take another look. In 2005 I almost lost the ministry God had gifted me for and called me to because of depression. Dr. Gregory Knopf, my medical doctor at the time treated me with skillful, tender, compassionate Christ-centered care and saved my ministry. Dr. Gary Lovejoy brings a pastoral heart to his profession and to this issue. If you are a leader in a church, this course will give you insights into people’s lives that will be productive. If you are struggling yourself with discouragement you will be encouraged and challenged.
In Lecture 4, The Elephant in the Room, Dr. Lovejoy mentions some self-assessment forms. You can find them in his book, Light on the Fringe: Finding Hope in the Darkness of Depression.
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Dr. Gregory Knopf and Dr. Gary Lovejoy
Depression: When a Member of the Flock Needs Special Care
Dr. Greg Knopf [00:00:05] Hi, my name is Dr. Greg Knopf. I'm a family physician in Portland, Oregon, and this is my best friend, Dr. Gary Lovejoy. He's a psychologist. Been in the counseling ministry for over 30 years. And we have a passion to help people understand the dynamics of what happens when people experience depression. One of the things that we talk about is, is that depression is actually an alarm system that helps us to recognize that something is going wrong, either in our spiritual life, our physical life, or our emotional relational life. Gary, tell us a little bit more about the dynamics of that.
Dr. Gary Lovejoy [00:00:48] Yeah, it's interesting because in depression a lot of people feel a sense of meaninglessness and purposelessness and the last thing they think is that depression has some kind of purpose to it, but in fact it actually does. And as Greg was saying, that that depression is an alarm signal designed to point out something that is missing, something is gone wrong, something is damage is either within ourselves, between ourselves and others or in our circumstances. And oftentimes all three, it is a alarm signal that tells us that we need to pay attention to the things that are hurting us and have damaged us in the past and will probably continue to damage us unless we seek to change it. In that sense, I think alarm as an alarm system that has a protective role. All alarm systems. Do you have alarm systems in your car to protect you from from ruining your engine? For example, you have alarms such as fire alarms and and other kinds of alarms which tell us to do something, to take some kind of action to protect ourselves. And we have a saying that we often give that that depression is to the psychological self as pain is to the physical self. What do we mean by that? Well, no one likes pain. Pain is miserable. It's a dreadful experience. In fact, we have a multibillion dollar industry designed to blunt the experience of pain. But pain is probably the most valuable sensory system you've got because it tells you that something is wrong in your body and that you need to pay attention to it. That's one of the reasons why pain is so obnoxious, is to get our attention so that we do do something about it. For example, if you walk down some steps and and twisted your ankle and suddenly you're in great pain, you take your weight off of your foot, in other words, you would limp. And if the pain persisted, you go to the doctor, get it X-rayed, and do whatever rehabilitation it was necessary. You wouldn't do any of those things if you didn't feel pain. So pain is has a protective function. Dr. Brand was defined it as pain. The gift nobody wants. It is a gift. And so and depression is very similar to that because depression is an alarm signal as well. And it tells us that something is wrong. It needs our attention to to enter for intervention and change. So so in this sense that depression is pointing out as an alarm system that it's not the problem itself, but rather it's a signal that points to the problem and that sends depression, oddly as it may sound, is really your ally, not your enemy, because it is forcing the issue for you to face things that may have been long since buried but needed to insure otherwise it will continue to damage you and your relationships. So this whole idea of the alarm system is reflects the mercy of God that when things are going wrong, things have happened to us. Pain, painful experiences have occurred in our lives. That when that happens, we have an alarm signal that tells us we need to pay attention to it or otherwise it will clearly degrade the level and quality of our life. This is God's mercy and action, really. And if we can see that so that we understand that is our friend and our foe, then we begin to look at depression an entirely different angle, and begin to look at what it's trying to tell us. So that's what we are talking about in terms of an alarm system.
Dr. Greg Knopf [00:04:29] And, you know, Gary, the the level of depression that is going on in our society is continues to increase. There are a variety of factors of that. But the World Health Organization recently has come up with some data showing that currently it's about number three as far as worldwide causes of overall disability and within about 7 to 10 years is going to be number one. So this is not an uncommon problem and it's becoming more prevalent as variety of factors come into play with sometimes the breakdown of the. Family isolation, other issues that come at the pace of our society, the disconnectedness. Other factors come into play.
Dr. Gary Lovejoy [00:05:13] Yeah, actually, that's a very good point. In fact, it's increasing rapidly. The incidence of depression in every demographic group and in every age group. And in fact, there are some 19 between 19 and 20 million Americans that are affected by depression and about 120 million worldwide. And that's really a lowball estimate because many are coming from third World countries where gaining accurate statistics is difficult to come by. But in any case, it's it's little wonder that depression is sometimes called the common cold of emotional disorders. And and it's even more important when we consider the fact that that for women it is the number one disability that one out of every four women in their lifetime can expect to have an episode of sometimes severe depression at least once in their life. And twice as many women experience depression as men. And and this is even more common in interesting enough in married women than it is in in single women, and particularly in young married women who have small children at home. And and of course, they are more likely to be subjects of physical and especially sexual abuse, which makes them great candidates for depression. And what is little known is that in terms of the suicide statistics, that while men tend to dominate in completed suicides because their use more lethal means such as guns, twice as many women attempt suicide as men. And so there is a lot of reason for the frequency of depression to be a major concern. It's particularly, as you said, is increasing and is predicted to increase. So if we as believers want to get a get again, a hold of what depression foretells with regard to the health of the body of believers, we need to really understand the idea of depression.
Dr. Greg Knopf [00:07:14] Yeah, yeah. The statistics show that about 70% of people who experience depression are women. About 30% are men, although sometimes I think it may be closer to 6040 because men do not acknowledge that they could be depressed. They act out in different ways. No, I'm not depressed. I just I'm just frustrated. I'm just going to spend some time with my buddies at the bar. And they may use alcohol or other means to sort of numb their pain, so they're much more reticent to seek help.
Dr. Gary Lovejoy [00:07:44] Actually, Greg, that might be a good I'm trying to talk a little bit about some of the characteristics of depression. How do you how do you recognize depression when it actually happens and people come in to you and they have an uncertain symptoms? What what array of symptoms do they likely show?
Dr. Greg Knopf [00:08:01] Yeah, that is one of the key points about depression, is that not everybody experiences that in the exact same way. So some people can have anxiety with their depression, other people have a lot of fatigue. So the classic symptoms of depression are feeling a sense of hopelessness and feeling discouraged and and a sense of of lack of meaning in their life. But the other major symptoms that are oftentimes associated with it, our number one with sleep issues, oftentimes where someone comes in to my office and says, you know, I get to sleep, but about two or 3 hours later, I wake up for no reason. Bingo, A light goes off in my mind that says this person could be experiencing depression because sleep issues are a major factor which comes first. Do they have sleep problems causing the depression or oftentimes is depression causing the sleep issues? And then lack of interest is another one. You know what? I just don't want to go hunting this year. I don't want to go shopping. I don't want to be by family. I don't want to go to the party. I want to isolate. I want to withdraw. So lack of of interest in their common activities. Another one is guilt, but it's generally not true. Guilt is actually what I call false guilt. It's a sense of, you know what? I just don't deserve to be happy. People would be better off if I wasn't here. You know, my life is really meaningless, a burden on and a burden on other people. And it's not over something I've done. It's just a sense of, you know, what? I deserve to just whatever it is. For some reason, I'm just experiencing this and it's my fault. And then a major one and probably about 50 to 70% of people who experience depression are going to experience lack of energy or fatigue. And fatigue is just huge. In fact, if a person comes in to my office and says, I'm just tired all the time. Yes, I will check them for a little thyroid. I will check them for anemia, for kidney and liver problems, a variety of physical illnesses. But oftentimes, if all those tests check out, then most likely they are experiencing depression on the basis of the lack of norepinephrine and dopamine in their brain, which is one of the neurotransmitters which we'll be talking about later. So fatigue is is a major one. Sometimes people have problems with concentration. They just can't focus. They just can't stay on tasks. They're not motivated. Things just become overwhelming to them. Sometimes people, when they get depressed, they have appetite changes. Some times people when they get depressed, they eat because every time you eat it actually raises your serotonin level and they eat to feel good rather than to maintain their body weight. Other people.
Dr. Gary Lovejoy [00:10:57] Compulsive eating like.
Dr. Greg Knopf [00:10:58] Compulsive eating, other people, when they get depressed, they stop eating. They just avoid they just again withdraw and hibernate. And then another one is. Sometimes people get agitated with depression or they'll experience physical heart palpitations and either revved up or feeling just exhausted. And then the last one is thoughts of suicide. And it may not be actual plans. I'm just going to, you know, next week I'm going to do it. It's just sort of, you know what? I just think that the world would be better off if I wasn't here. So those are some of the major symptoms that we have. And in fact, I'd like to show you a short video of a young woman who is experiencing depression and her name is Tanya. And I think it will demonstrate some of the symptoms that you oftentimes see that I see every day in my office when people come in to discuss some of the things that they're going through.
Dr. Gary Lovejoy [00:11:54] The women and.
Dr. Greg Knopf [00:11:54] Men appearing in this video are not actors. They are real patients who are being treated for depression, describing their experiences in.
Speaker 3 [00:12:04] Their own.
Dr. Greg Knopf [00:12:04] Words. Dr. Arnold Mack is a psychiatrist and clinical investigator based in Plano, Texas.
Speaker 4 [00:12:24] These Do people have been depressed but are in remission? Today, a consensus is growing among clinicians calling for a higher standard of care. Remission in the treatment of depression and anxiety. Remission is usually defined as minimal or no symptoms on one or more standard assessment scales. For example, on the Hamilton Depression rating scale, which is the standard evaluation tool used in clinical antidepressant trials and will be referred to throughout this film, Remission is defined as a score of seven or less. Other physician or patient rated itemized symptom measures can also be used in clinical practice to accurately evaluate patient's progress. I highly recommend using one of these evaluation tools rather than overall impressions to monitor a patient's progress toward remission. Missing this opportunity to quantify symptom response in remission is akin to treating hypertension without a blood pressure cuff. In this film, we will use several patient profiles to put a face on remission, as well as the stages leading up to it. As you can see in this graph, adapted from Dr. David Kupfer, patients treated for depression progressed through several phases, from fully symptomatic to response to remission and finally to recovery. As you meet the patients in this film, we hope their examples will help illustrate the reasons why physicians have increasingly begun to view treatment options targeting remission as a first step toward complete recovery from depression and anxiety.
Speaker 5 [00:13:46] I have trouble concentrating from not being able to learn people's names, to not even knowing what they say to me. I've hidden away from people. I'm not very social. I lost interests, interests and a lot of my hobbies. I used to scrapbook and crochet and I felt like a horrible mother, very worthless. And I didn't feel fit to be their mother. I just. I felt really down suicidal.
Speaker 3 [00:14:26] She'll use the the bedroom as a cocoon, basically, and hide off in there, not having the energy to even want to be around the kids or the family.
Speaker 5 [00:14:38] I want to block the whole world out. I'm not able to work at this time and. It's even though I'm there all day long, it's hard for me to do the laundry or to do the dishes or to make dinner for the kids.
Speaker 3 [00:14:53] It becomes overwhelming to do anything. And that's probably the biggest clue that she's starting to feel down is that everything becomes such a chore and she feels so overwhelmed.
Speaker 5 [00:15:08] It's hard to go to the grocery store some days and get things that we need. I don't play games with the children anymore like I used to, and that makes me feel very guilty when my son comes up to me and says, Can we have a game night? And I'm looking at him going, I'm sorry, I'm I'm too tired. I can't do it tonight. I don't think the road to getting better is as long as I thought it was. A few months, maybe even a few weeks ago. It's not a hop, skip and a jump away. Just. It's there. I know it's there. I was crying a lot. I mean, like, constantly, for one thing. And I began to not be able to function. I start losing work. I would go in for an hour or two and I couldn't concentrate or I'd get upset, you know, start crying again. I had to come home, didn't take care of anything during the day. Nothing. Just laid around and cried and did nothing. My 12 year old just had a real problem with me being upset, hurt and upset all the time, crying all the time. He learned to to not talk to me much, to stay away from me, because I was really if I would talk, I'd be snapping. I don't know if my two and a half year old really caught what was going on, but sheesh, all she got was the crying. But I'll make a decision about three months. It actually lifts the fog that's helped me with my two and a half year old to be more patient. What's under the table? That baby has a baby. I feel like my 12 year old relating better. And now I can look at him and say, You know, Nathan, I'm sorry. I'm just hurting today. I still get bad days during the week, maybe a couple of days a week, you know, wanting to work three or 4 hours and then, you know, just veg out, not wanting to cook that night. Not like it used to be to where you really can't do anything. But you still know that you're walking out the door and feeling of down feeling all day. I want to be able to be excited about being a mom and be able to dress my daughter every day the way she needs to work instead of just throwing something on her big white hat. I want to be able to actually look forward to coming home and get cooked and get the dishes done and get longer done. Instead, I feel like it's a bargain to get up in the morning and, you know, take a shower and get ready for work. And if something does hit, you can look at it for what it was and go on and not think about it for two or 3 hours. I want to be able to do that. I want to be able to do that every day. There was there was a time where I was so deep in and depression. I was I had convinced myself that my son would have a better life if I sent him off and had, you know, somehow tried to get him adopted. I was just totally exhausted. I would end up just sitting on the couch watching him play, basically, you know, I didn't have the energy to be there for him physically or emotionally or mentally or any of those. I was just I came to the point where I was just kind of involved in myself and just wallowing in my misery. I feel that, you know, since I've started on the medication, since I've been on it for a while, that I've I feel like I've come a long ways. I'm, you know, now I'm willing and I want to spend time with my friends and, you know, go out and go to the movies or go shopping. My feelings towards my son just totally changed. I just look forward to doing things with him up here, um, taking him out to the park, playing with him. When I think of being a mother now, I just, I feel. I feel like. Like it's a gift that's been given to me for me to, you know, pour my life into my son and, um, make him a better human being. And I look forward to going pick him up, you know, just to see him. And because whenever I pick him up, you know, I come inside and he's like, mommy, and he's so happy to see me. And and I'm. I feel the same way towards him. I know that I'm not 100% back to myself yet. I'm I'd say maybe about 75%. I was doing photography pretty seriously. And then the the depression kind of started and I was no longer into photography. I didn't really care about anymore. It didn't really bring me any joy. Now I want to get back into it. I really enjoy it. And and I hope to maybe pursue it as a career if possible. I'm definitely on the road to, you know, recovering fully. And there still are moments and days when I, you know, feel depressed and kind of go back into my old thinking pattern again. And so it's not, you know, all wonderful all the time, but I'm definitely getting better and I'm actually looking forward to getting better and looking forward to the process that's going to lead me there.
Speaker 4 [00:20:29] These three patients you have met illustrate distinct stages in the treatment of depression. The first patient was fully symptomatic and was just beginning antidepressant therapy. The second and third patients had been on therapy longer and showed progressively greater degrees of improvement. However, both of these patients remained at a level of a response to therapy and had not yet achieved remission of symptoms. Clinical experience has demonstrated that response is an insufficient standard of efficacy and can have disturbing consequences if patients stop at this level of symptom improvement. A response to therapy still represents continuing illness in a milder form. Causes Continuing functional impairment is associated with increased suicide rate. Furthermore, for patients with only partially resolved symptoms, depression can become a vicious cycle. Such patients were four times more likely to have further depressive episodes and have been estimated to have a 20% chance of remaining chronically depressed. On the other hand, patients treated to remission are far less likely to relapse, but remission is more than an absence of symptoms of depression. Remission is also a resumption of favorite activities, attitudes and general approach to life, As the following cases will illustrate, patients who achieve remission return to their normal level of functioning. Patients in remission are doing things because I want to, not because I have to resume social activities, hobbies and personal pursuits and can tolerate minor disappointments and are able to take life in stride.
Speaker 5 [00:21:59] I could not stop. The tears could not. It was the end of the world. I couldn't get it out of my mind. I would just torture myself with whatever thought was bothering me. Prior to the medication raising children, it was like everything else in my life. And if the slightest thing went wrong, I was a horrible mother and I felt guilty and I'd beat myself up. And in order to punish myself, I would punish my family. So I would snap at the kids or yell at the kids or I just I wasn't the person, the mother I wanted to be. And then when I was like that, I hated myself. The girls. You can stop now.
Speaker 3 [00:22:43] In the band days. She'd have a meltdown. A really bad situation will be very, very stressful and very, very angry. Shouting. I do remember one particular episode where we were fighting over something I don't recall, but the end result of the argument was, is that she was in tears in the closet, hiding behind a bunch of clothes.
Speaker 5 [00:23:10] After I started medication, he actually asked me when I were sitting in a restaurant and he said, You know, I've noticed that you seem so much more relaxed and in control. What's up? Because I had never told him that I was on medication. You could call it denial, I guess, but maybe it's more that I wouldn't accept the fact that I was depressed. Oh, now I know that I was and had a problem and fixed it.
Speaker 3 [00:23:40] She's fine. She's good to get along with.
Speaker 5 [00:23:41] I'm a good person. I'm a good mother. I'm a good employee. If something goes wrong, there's none of this. You know, I had just gone off the deep end stuff anymore. Depression is not part of my life.
Speaker 6 [00:23:54] I was crying a lot. I felt like crying. I felt pretty much zero self-confidence, zero self-worth. I had a hard time focusing on things. I didn't like to do anything. I didn't care about anybody. I remember at work one time my manager came and took me outside out on the patio and and said that people are people that I work with, were wondering if I was really here or not. I truly didn't want get out of bed in the morning, you know. I wanted to just lay there and and hide. When I first started taking the medicine, I noticed that I saw I started seeing an improvement. And gradually over a couple months, I started feeling really well. I had forgotten what it was like to feel good again. I felt good then I felt better. And now I feel great. I wasn't as exhausted and tired. I was sleeping better. I felt like interacting more with my children and with other people. Teasing the kids and singing them, making up little silly songs and. And doing silly dances and I was more normal again. It was more like me. Before there was a cloud and there was a brick wall and I. I just could never get past it. I was always bumping up against it. But now I feel like it's completely open. I can think clearly. I look forward to the day and for what's going to come and what's going to happen. And and I don't think about what if this happened. So what if that happens? You know, I just hope it does. Okay. We'll deal with it at that point. And I have a much better relationship with my wife now. We see more eye to eye on things. My relationship with the children is much better because I'm making an effort to be involved in their life and they're responding better.
Speaker 5 [00:25:39] Yeah, right. Yeah, yeah.
Speaker 6 [00:25:40] One thing that I like to do when. When I need a release. I'll go in and either play the piano or play the organ. But before, when I was depressed, I would be so tense that I wouldn't even want to go in there. And even if I did go in to play something, I couldn't concentrate. And it could be inspired, if you will, to let the music flow. Of course, I have good days and bad days. A bad day before was really bad. A bad day now is just. Well, things didn't work out the way I wanted it to work out. Maybe next time it'll be okay. But I don't have depressed days.
Speaker 4 [00:26:19] As you recall, the patients you have seen in this film. It should be clear that the difference between response and remission is a difference in remaining half depressed and being symptom free. Between risking relapse and experiencing optimal long term outcomes between merely existing and a full resumption of the activities that make life enjoyable and fulfilling. While a number of factors can influence clinical outcomes, the choice of antidepressant may be critical in achieving the goal of remission. Because depression or anxiety may be related to disturbances of more than one neurotransmitter system, it makes sense that antidepressants with a combined mechanism of action may produce a more robust response in a broader range of symptoms and help more patients reach remission. As these patients have demonstrated, remission of symptoms is a first step on the road to recovery. The time has come to reach for the goal of remission, complete symptom resolution to offer more patients a chance to get their life back again.
Dr. Gary Lovejoy [00:27:17] I think one of the things that you were saying, Greg, that really conveys more than anything the tremendous gravity of dealing with the issue of depression is the last symptom. You were talking about suicidal ideation and and attempts, because this is something that is increasing. In fact, there are some quarters who are talking about suicide as epidemic, and especially among young people. We're seeing it at an earlier early age and sometimes suicide homicide. So you see some of these young people committing atrocities on the culture. But then they turned the gun and.
Dr. Greg Knopf [00:27:51] Suicide by cop.
Dr. Gary Lovejoy [00:27:52] They purged. Exactly.
Dr. Greg Knopf [00:27:54] I'm not going to I don't have the guts to do it myself. So I want the cops to kill me.
Dr. Gary Lovejoy [00:27:58] That's right. So they set it up so that they are. Exactly. Now, one of the things interesting about depression is that it is not just a random assortment of the symptoms that that Greg was talking about. It actually occurs according to certain patterns that are determined by the emotional associations we build up through life. Let me give you an example of what I mean by emotional associations. Have you ever met somebody for the first time and and you you just had this negative feeling toward them and they're not saying if I asked, you know, did they say something bad? They they show disinterest in what you're saying. Did they did they mock you or something. And and every question I would ask you would say, no, no, they didn't do anything. But I don't understand why I feel that way, but I just feel negative toward them. What's happening in a situation a lot of people experience that. Well, that's really what is called an emotional association. What happens is this They're the memory of a specific event for which the emotional association was built is long since been lost. They may have had a bad experience with someone who had a particular characteristic that that person that you're interacting with. It might be a gesture, it might be a facial characteristic, it might be their posture, how they talk to any any number of behavioral or verbal kinds of triggers that can trigger their most association with someone you actually did have a bad experience with, but you've forgotten the memory of that experience. But the emotional association lives on. And so it's trigger when the right circumstances occur. For example, if and quite frankly, from very early childhood, we begin associating emotions with different types of people and situations. For example, a woman who was raised by an abusive father is going to come to fear old men, or at least increased likelihood of doing so. A man whose family got drunk and mean at Christmas will become inexplicably to those around him, sad and depressed during the holidays. Or a woman that I worked with whose parents who had vicious, vicious arguments, in fact, actually in physical altercations at the dinner table every almost every night and made their kids continue to sit at the table through all these toxic events. And she came to associate eating with all these toxic events so that as an adult she became anorexic and fairly aversive forms of it. Know when people have a long history of pain, they have a tendency to know. They don't understand, first of all, why their life doesn't get any better. But in reality, what they're often doing and it's makes sense what they're doing, and that is they tend to erect walls to protect themselves from any further hurt. But those same walls also block positive, more redemptive experiences. They can transform their world into something far better. But they do because of these emotional associations. And these emotional associations are what respire what is responsible for the the different kinds of expressions of depression. So it's not just a gray. I think you mentioned that all depression is not the same. It comes out in different packages. Well, indeed it does are actually five common patterns. The first pattern is and these are determined by the emotional associations that I'm talking about. The first pattern is withdrawn depressives. These are people who have a typical hopelessness, helplessness, sense of emptiness, low self-esteem, some of the other symptoms that Greg was mentioning. But they're also marked by a kind of apathy, a kind of given up quality about them. They withdraw from people. I think you mentioned that they withdraw from people. They prefer isolation. They're the kind of people will walk in and sit down, close the door and turn off the lights and sit in the dark for hours, or just stare blankly at the tea, at a TV going on. And fact Michael Card, the well-known musician, had. Talked about his father, who was was a physician and he would come home. We barely acknowledge the family. When he walked in, the door would walk straight back to the den, close the door, lock it, turn off the lights and stare into space for hours. And Michael Card would try to talk as a little boy to his father under the the crack into the door. He says. For the large part, that was my entire relationship with my father. This is these are withdrawn, depressive. Then there are dependent depressive and dependent depressive have again all the same characteristics, many of those same characteristics of depression, including hopelessness and helplessness and so forth. But they are also marked by overwhelming interpersonal anxiety. So that so that in the process they develop a kind of clinging, dependent type of relationships with others. So that in a quite contrary to the withdrawn depressive, they will actually seek people out, but make all sorts of heavy demands on him and literally drained them. Drive ever known someone like that? They're in constant search for rescuers. And then there's a third pattern, which is what I call somatic depressives. And these people express their feelings and a variety of bodily symptoms of one kind or another. They tend to express their feelings in and persistent, often exaggerated physical complaints. And in effect, what they're doing is they're channeling their depression through their bodies. We often refer to them as hypochondriacs. That's what you might have heard. But in reality, they are depressed people in a constant search for personal significance. And then they're the angry depressives. And these people are express their feelings and kind of persistent, sometimes intense episodes of anger, even rage toward others or toward themselves. And they there's a sense of gloom and doom that saturates their conversation and in a sense of self-blame or blaming others, they are the ultimate pessimist. And as a result of that, they're very difficult to live with. And if you don't believe me, just ask their spouses. Their divorce rates are quite often quite high. And and then the last symptoms, the last organized pattern is anxiety depressive and anxiety depressive. People are constantly worried. They're worried about everything. They create worst case scenarios about almost every circumstances. And and when they do, they increase have increasing anxiety where they may even have attacks, where they have heart palpitations and and shallow breathing and tightening of chest and of and the feelings of impending doom. And oftentimes they end up in the air thinking they're having a heart attack and these are anxiety attacks, or they might just simply have free floating anxiety where they're just always nervous all the time. It's important to keep in mind that anxiety is a common component of depression. I think you mentioned that great anxiety is often a precursor to depression. As a matter of fact, sometimes it's a relatively reliable cuteness impending onset. And in this situation, anxiety is a kind of signal is telling them that they feel insecure in hand and in their adequacy of being able to handle life's challenges that are filled with a kind of fear that they will be hurt in some way. They're emotionally, most likely or physically, a fear of rejection. For example, people feel hurt when they feel that they don't matter, that what they say, what they feel, what they believe simply doesn't matter. In fact, that's the root of many arguments that occur between couples is because one or both feel that that they just their view just doesn't matter. I've had clients say, well, doesn't matter. He's going to do what he wants anyway. It doesn't make any difference what I think what they are, they say they say I don't matter and their depression is not falling behind them. In that kind of situation. Anxiety is is more an anticipation or a fear of getting hurt. But anger is the most common response to being hurt. And anger is a cover for our vulnerability. We don't like to feel vulnerable, and so we strike back in defense instead. And so you see these different patterns of depression. It's interesting that there are actually gender differences in terms of these patterns. Men tend to predominate among angry depressives and to some extent withdrawn depressives, but women tend to predominate in anxiety depressives and dependent depressive and somatic depressives. So there is a gender difference there. But nonetheless, all of these patterns represent difficult experiences, and sometimes they show up in the church by conflictual relationships, things that happen in the church. And you wonder, how do all of this happen? And oftentimes the participants in those conflicts are, in fact, oppressed. But you don't see them as depressed because we are not trained to understand some of the more subtle characteristics of depression that some of these patterns take.