New York – The Rambam talks about depression, referring to it as ‘marah shechorah’, which literally means “black bile.” In his time, it was thought that there are four types of body fluids, and when these are not in proper balance, disease results. Depression, Rambam says, is due to an excess of the black bile.
This of great interest, because the Rambam was centuries ahead of his time. In fact, in 1961, when I began my psychiatric training, it was believed that depressions are due to psychological causes, and treatment was directed at understanding and remedying these causes. The reasoning went something
like this. When a person suffers a loss, one become depressed. Therefore, when a person is depressed, one must look for what kind of loss one sustained.
In the 1950’s, it was found that derivatives of the rauwolfia plant could lower blood pressure, and these drugs were welcomed by medicine. Although the drugs did indeed lower blood pressure, they had a side-effect of causing depression, sometimes even resulting in suicide. This indicated that depression can also be caused by a chemical change in the body, in this case brought about by a medication. It was subsequently found that chemical changes in the body can also result from viral infections, the stress of surgery, exhaustion and hormonal changes, such as occur in premenstrual and postpartum women. Sometimes these changes are of genetic origin.
The important point to realize is that a person may be depressed even in absence of a psychological cause, but due to chemical changes in the body. These types of depression can be effectively relieved by appropriate medication. This was Rambam’s understanding of depression 800 years ago.
The most common symptoms of depression are sad mood, loss of interest in things, difficulty concentrating, either loss of sleep (especially early morning awakening) or excessive sleep, loss of appetite, decreased libido, crying without a reason, and hopelessness. As these symptoms progress, a person may develop a death wish and may attempt suicide.
The incidence of depression in the Jewish population is significant, and this maybe because of a genetic vulnerability.
However, it must be remembered that “depression” describes a feeling, and that a person may indeed feel depressed even though there was no chemical change in the body. A person who grieves the loss of a loved one may feel depressed. A person who lost his job or is experiencing an adversity of any kind may feel depressed. Inasmuch as such depression is not due to a chemical change in the body, antidepressant medications are of little help. But it is possible that the grief and worry may actually produce a chemical change, so that a chemical depression is superimposed on the reaction to adversity.
There are also some people who have a “depressive personality.” They are chronically unhappy and just do not feel that the world is a nice place to live. This attitude may begin in childhood, so that there are children who “mope” for no apparent reason, and are chronically dissatisfied. Many cases of depressive personality are due to low self-esteem, which I described in my books Life’s Too Short and Angels Don’t Leave Footprints. This kind of depression generally does not respond to antidepressant medication.
Depression due to a body imbalance is generally referred to as “clinical depression.” It may last from several weeks to many months. It is not unusual for clinical depressions to recur. If medication has provided relief, it is a serious mistake to stop the medication when one feels better. Medication may be discontinued only by doctor’s instruction. Unfortunately, there is no laboratory test to determine whether there is a chemical imbalance, and it requires the diagnostic skills of a doctor.
A person suffering clinical depression needs competent treatment. It is wrong to tell him “Just pull yourself together,” just as it would be cruel to tell a drowning person “Just pull yourself together.” This is adding insult to injury.
Because depression are quite common in the Jewish population, it is important to gather information on the condition, so that proper help can be provided at the earliest time. Untreated clinical depressions can progress to very serious consequences. Refusal to seek help because one does not wish to be “stigmatized” as a psychiatric case is the height of folly and may be very dangerous.
Of course, one should pray to Hashem for help. Halacha requires that a person take antibiotics for pneumonia and the proper medication for diabetes. Refusal to take such medications is being a chasid shoteh (pious fool). Depression is no different. One must seek proper treatment and pray to Hashem for a refuah.
Rabbi Dr. Abraham J. Twerski D is an ordained rabbi, graduated from Marquette University Medical School and is the the author of more than 60 books.