A Biblical Evaluation of Major Depressive Disorder as Expressed in the DSM-5TR

Diagnostic Criteria and Secular Treatments

A diagnosis of major depressive disorder is made by the consideration of at least five out of the nine symptoms provided in the DSM that are all simultaneously present during a two-week time frame. At least one of those symptoms needs to be either a “depressed mood or loss of interest or pleasure”.[1] Some of the other symptoms would be a change in appetite or sleep to an extreme of the lack or abundance of either. Also experienced by the counselee may be feelings of worthlessness and fatigue, or frequent thoughts of death or suicide.

            There are five categories of criteria listed within the DSM for MDD. The first category is the symptom criteria aforementioned. The second category is of functional impairment. Functional impairment refers to if the syndrome experienced by the counselee has become a hindering obstacle or impairment in their ability to function socially, at work, or in other ways. Next, other possible causes need excluded such as the use of any drugs or medication, or another medical condition. The fourth criteria category ensures that the experience of the counselee is not better explained by another disorder, and provides some possibilities such as schizoaffective disorder, schizophreniform disorder, delusional disorder, or the other conditions mentioned. Lastly, the individual must not have had a manic or hypomanic episode.

            The most widely used and credibly recognized treatments for major depressive disorder include depression focused psychotherapy, prescribed serotonin reuptake inhibitors, and in some specific cases electroconvulsive therapy.[2] It should be mentioned that even these most common treatments are explained to be purposed towards the goal of perpetual management in order to “maintain remission and prevent relapses”.[3]

            There is overlap in the medical model and secular psychology in explanation of a mental disorder because fundamentally both give the label of an illness or disease with biological or neurochemical causes. That said, the psychological perspective would bring in more nuance to include the complexities of human behavior and emotion associated with everyday life. So, for major depressive disorder, it is not only understood as a matter of biology and the need for serotonin reuptake inhibitors, but also psychotherapy for the behavioral and emotional aspect in managing the illness.

A Biblical View of the Symptoms

As demonstrated, the nine symptoms for MDD are listed within the first criteria point. When non-believers experience these things, it should serve as a wakeup call to where true purpose and satisfaction is found alone. For the believer experiencing them, it is a call towards more fervent participation in the means of grace. More simply, negative emotion serves as a signal telling the believer it is time to pray, congregate in fellowship, do good works of mercy, remember at His table, and to open their Bibles.

The most prevalent of these symptoms include a consistent depressed mood indicated by feelings of sadness, emptiness, and hopelessness. For the unbeliever, the Augustinian God-shaped hole in the heart is a very real and Scriptural notion that shouldn’t go ignored. When Paul spoke to the Athenians, he affirmed that God made humanity with the intent that they would seek Him. Paul describes them as seeking God in the hope that they might feel their way toward Him and find Him, but all the while God is not far from anyone (Acts 17:26-27). It is for this reason that Augustine wrote in his Confessions, book 1, “You have made us for yourself, O Lord, and our hearts are restless until they rest in you”.[4]

Negative emotions such as depression, sadness, emptiness, and hopelessness, are the consequence of a lack of joy, which is a fruit of the Spirit (Gal. 5:22-23). This is the case also with other symptoms mentioned further down in the list provided by the DSM including “feelings of worthlessness or excessive or inappropriate guilt”.[5] What the counselor finds in Scripture is that there are many cases of individuals experiencing these symptoms. Elijah isolated himself and even asked God to take his life (1 Kgs. 19:4), Job expressed feelings of hopelessness (Job. 7:6), and David showed a variety symptoms on many occasions (Psa. 38, 42, 43, 69).

Feelings of worthlessness often come when one faces the truth of their depravity, but attention should be shown to those experiencing this, their value as image bearers who are fearfully and wonderfully made by God (Psa. 139:14). Often one might experience the symptom listed of excessive or inappropriate guilt. If over sin, this can be a healthy and mature sign (Matt. 5:4), but in inappropriate or delusional excess, Scripture gives many reminders towards what Chrysostom once prescribed, “Let no one mourn that he has fallen again and again; for forgiveness has risen from the grave”.[6]

Other, more physical symptoms listed, such as weight gain or loss, and either the lack or excess of sleep, and the more minor ones such as fatigue or lack of concentration should be improved as the spiritual problem is addressed, dealt with practically, and some time passes. But these too can be observed in Scripture with the same individuals mentioned prior. David wrote once of how he felt like an owl alone in the wilderness or sparrow all alone on the top of a house, and made mention of the fact that he would be awake all night thinking those thoughts (Psa. 102:6-7), and sometimes he would flood his bed with tears all night (Psa. 6:6).  He also said he grew tired and his bones grew weak (Psa. 31:10). Job expressed tossing and turning throughout the night waiting for the next day to come (Job. 7:4). What is important to remember is that not only does Scripture show symptoms, it shows us Christ in the midst of them, and where the believer finds their joy and hope.

Conclusion

I believe the secular diagnostic criteria fall woefully short of what is offered in Scripture. If someone came to me wanting biblical counseling, and said that they were diagnosed prior with MDD, it wouldn’t be completely meaningless to me, and I wouldn’t disregard it because it’s helpful to know they have a history of the symptoms within the criteria. However, I wouldn’t affirm that label, or cosign for the diagnosis. My reasoning is because the criteria overlook far too much that simply should never be overlooked by someone who holds to a Christian worldview, especially a pastor trying to help someone.

Most obviously, the DSM 5-TR overlooks spiritual factors that would cause depression. There is no consideration of man’s sin nature. Where Scripture says, “The heart is deceitful above all things, and desperately sick; who can understand it?” (Jer. 17:9), the psychotherapist tries to answer that rhetorical question by asserting that they can understand the sickness of the human heart, but meanwhile ignore the mention natural deceitfulness. So man’s condition is treated only as sickness, rather than as a spiritual problem of the heart.

What this then looks like within the DSM model is that human suffering, here in the form of depression, is regarded as value neutral and involuntary. It’s an experience that passively happens to someone, that they are only ever the victim of, to be eventually written off as the product of trauma or a so-called chemical imbalance. It ignores moral agency, as well as any spiritual evaluation.

One of the examples I used in the Biblical section was David, and in one of the most gut-wrenching Psalms he offers, even in the midst of his despair, he acknowledges the moral and volitional aspects to his suffering. He is transparent about his soul feeling cast down and in turmoil within him, and immediately responds to it by saying, “Hope in God; for I shall again praise him, my salvation” (Psa. 42:5). I do believe that there is a circumstantial element to depression, but even then, it’s still the product of being a fallen person living in a fallen world. So, David gives an example for believers sharing in this feeling that it can be related to something such as misplaced hope. For others it could be unconfessed sin or neglecting the means of grace. Whatever it may be, there is a moral and volitional aspect that is entirely ignored within the DSM which is woefully incompatible with the Christian worldview.

In conclusion, even though the criteria for MDD in the DSM offers a description that could potentially help to indicate habits and symptoms of depression, its categories are limited to that, and offers nothing in terms of hope and healing for the spiritual reality of the situation. The biblical worldview maintains that human beings are moral agents due to the Imago Dei, and that their suffering is not only due to material or psychological circumstance, but due to sin; original, willful, and involuntary. Therefore, as a minister I cannot view the MDD label provided by the DSM5-TR as authoritative or sufficient because the care of my congregation is a matter much deeper than mere symptom management.

BIBLIOGRAPHY

[1]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. TR (Arlington, VA: American Psychiatric Publishing, 2022), 184.

[2] Karrouri, Rabie, “Major Depressive Disorder: Validated Treatments and Future Challenges.” World Journal of Clinical Cases vol. 9, 2021, 31. Major depressive disorder: Validated treatments and future challenges - PMC

[3]  Ibid.

[4]  St. Augustine of Hippo, Confessions, 1, 1.5. St. Augustine of Hippo: Confessions

[5]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. TR (Arlington, VA: American Psychiatric Publishing, 2022), 184.

[6]  St. John Chrysostom, The Paschal Homily, St John Chrysostom's Easter Sermon