The “black dog”
Teens test-drive a variety of emotions every day, and sometimes they have no idea how to explain or express them. We’ve all heard (or even said) something like, “I’m so depressed! They canceled my fav show!” or “I’m so anxious about my math test!” The language of mental illness runs rampant through our casual conversations. It’s not all that surprising, though. These days it’s like everyone on earth has a microphone, and with the racket of everyone’s opinions, hyperbole seems a useful method for getting heard. The louder the noise, the less others want to listen, so we employ exaggerations to describe how we feel and to connect with others.
But things like depression and anxiety are no exaggerations: Rick Warren, pastor of one of the largest evangelical churches in the U.S. and author of one of the bestselling books in history (The Purpose-Driven Life), lost his son Matthew to suicide after a long battle with a serious depression disorder. Author, pastor, and Southern Baptist Convention president Frank Page wrote a well-read book about his daughter’s severe depression and eventual suicide. A quarter of pastors (yes, pastors) admit to having suffered with a mental illness themselves, most often depression or anxiety, and many of them since childhood. Even Winston Churchill suffered terribly from a lifelong, untreated mood disorder he called a “black dog” that would sit on his lap and haunt him. So let’s talk about this black dog and how you can help your teen more effectively cope and find healing.
An important note
This guide helps parents know more about the troubling incidence of depression and anxiety disorders in the lives of young people. Like our other Parent Guides, this tool provides knowledge, references, and faith-based encouragement on the subject to help parents connect with their kids. However, we do not pretend to be physicians, healthcare providers, or even experts on these difficult matters; as such, this resource is NOT a substitute for medical advice or treatment. It can accompany and support actions directed and/or confirmed by a qualified healthcare professional, but it is not meant to replace or preclude any diagnosis or treatment by a qualified healthcare professional. Axis cannot be responsible for actions taken without professional medical guidance.
We cannot say it loud enough or often enough: If you even suspect your child has suicidal thoughts or plans, stop reading this and take action now. Contact your family physician and tell them your teen is at risk of suicide and must be seen immediately. If a doctor cannot see them right away for whatever reason, do not leave your child alone until they can be seen and evaluated by a healthcare professional qualified to assess adolescent behavioral health. If necessary, take your child to the nearest emergency room or urgent care center, demand priority, and do not leave the physician’s office until next-steps are in place (such as referral to a specialist, assessments, evaluations, treatment plans, outpatient/inpatient programs, etc.).
What are depression and anxiety?
Clinical depression and anxiety disorders go far beyond “the blues,” grief, tension with a cranky teacher, or irritation with a friend who didn’t text back. When a person presents a severe, longstanding distortion in mood that doesn’t match current circumstances, mental health care professionals refer to it as a “depressive disorder” or an “anxiety disorder.” These conditions, grouped into a category of illnesses called mood disorders or affective disorders, impact daily lifestyle, relationships, personality, and sometimes cognitive functioning. They require professional medical care to resolve and, left untreated, can result in devastation for sufferers—and their loved ones.
Anxiety disorders are the most commonly diagnosed mental illness in the US, affecting more than 18% of the population every single year. Major depression carries the heaviest burden of disability; every year it affects more than 16 million adults and 2 million teens ages 12 to 17 severely enough to impair their daily lives. There are different forms of depression and of anxiety, each of which affects a person differently and requires different approaches for treatment.
Yet fewer than a third of those suffering from these very serious mental conditions ever receive treatment, despite the huge potential for treatment success. At the same time, LifeWay Research reports that nearly half of evangelical, fundamentalist, or born-again Christians (48%) believe that people with depression, anxiety, and other serious mental illnesses can overcome their condition by praying more often, growing in spiritual maturity, or reading the Bible more.
Are depressed/anxious teens just experiencing the normal ups and downs of growing up?
Psychiatrists began to focus on mood disorders in kids during the late 1980s, but they had trouble with diagnosis at first because kids don’t always present the same symptoms as adults. Physicians and researchers now know that typical onset of mood disorders, including depression and anxiety, happens as early as age 11, and as many as 8% of all teens suffer from a severe emotional disturbance as defined by the Substance Abuse and Mental Health Administration, most often an anxiety disorder.
The World Health Organization reports that 10-20% of children and adolescents worldwide experience mental disorders, and half of all mental illnesses in adults begin by age 14 and 75% by mid-20s. Neuropsychiatric conditions are the leading cause of disability in young people in every region on the planet. The World Mental Health Survey confirms this, showing that although many mental disorders begin in childhood or adolescence, “diagnosis and treatment may be delayed for years.” Stanford Children’s Health calls mood disorders in children and adolescents “one of the most underdiagnosed mental health problems.”
If left untreated, depression and anxiety disorders severely influence a person’s development, their ability to achieve and succeed in education, and their hope of leading fulfilling, productive lives. Young people with mental disorders also must deal with stigma, isolation, and discrimination, as well as lack of access to health care and education facilities.
Sadness, grief, fear, worry, distress, loneliness—it’s true that these emotions should be expected during times of loss, failure, trauma, disappointment, and difficulty. Teens and healthcare professionals refer to these as “triggers.” Jesus Himself acknowledged the problems this world will bring us when He said, “In this world you will have trouble…”(John 16:33, emphasis added). He also understands our sufferings because He Himself was described by Isaiah as “a man of suffering, and familiar with pain.”
Our “normal,” everyday feelings can be overwhelming to say the least and must be properly explored. Teens may withdraw, cry, rage, refuse to eat, have trouble sleeping, etc. because of a difficult circumstance or painful experience; it does not necessarily mean they are mentally ill. A teen’s mood swings can last a few minutes, hours, or days. As parents, we can and should teach our kids coping strategies and ways to obtain healthy support to prepare them for what Jesus spoke of as “the world’s trouble.”
However, mental illness can be distinguished from sadness, grief, and fear. Teens with depression can experience intense emotions and mood swings without any trigger at all. The American Psychiatric Association indicates a mood disorder diagnosis is appropriate when symptoms are “out of proportion to the situation, are age-inappropriate, or hinder a person’s ability to function normally.” In other words, when symptoms last weeks, when a person’s identity is affected, when nothing seems to help (even methods or activities that used to help), or when behavior changes in a damaging way for an extended season, it’s time to consider a mood disorder. By way of example, the APA explains how normal grief differs from major depression:
In grief, painful feelings come in waves, often intermixed with positive memories of the deceased. In major depression, mood and/or interest (pleasure) are decreased for most of two weeks. In grief, self-esteem is usually maintained. In major depression, feelings of worthlessness and self-loathing are common.… When grief and depression co-exist, the grief is more severe and lasts longer than grief without depression.
What causes depression and anxiety?
Sometimes the problem can be traced to just one factor, but most often a combination of dynamics initiate mood disorders in teens. Physiologically speaking, there are a variety of factors, chemicals, and processes that are involved. Beyond that, mental health care professionals say these illnesses can be triggered by or traced to:
- A high familial incidence of depression and/or anxiety;
- Life events such as abuse, trauma, loss, or neglect;
- Chronic high levels of stress;
- Chronic physical illness such as cancer, diabetes, multiple sclerosis, or heart disease;
- A congenital low stress-tolerance (which can now be determined through genetic testing);
- A high rate of metabolism of certain brain chemicals called “neurotransmitters” (like serotonin and dopamine) known to regulate mood;
- A dysfunction in the area of the brain where moods are controlled (known as the amygdala).
What are the spiritual ramifications?
Immobilized by a cognitive assassin, patients in the deepest throes of depression and anxiety have a hard time believing that God values and creates people with a purpose. Some believe their unbearable pain or numbness are character flaws. In some, their expectations and capabilities are irreconcilable, and symptoms get worse from the resulting frustration and embarrassment.
Because of all these factors, those with clinical depression or anxiety often understandably struggle in their relationships with God, which then also contributes to the downward spiral. When paired with bad advice from spiritual leaders (see next section), it can also result in doubting God’s goodness or that He even exists at all. This can then cause the sufferer to look for answers and solutions in other places that promise solace, comfort, and healing, but only lead to the opposite. However, when good spiritual advice is paired with good medical treatment, sufferers can find lasting physiological, spiritual, and emotional healing.
How can my church or pastor help?
“We have to break the stigma that causes people to say that people with mental illness are just of no value… I think Christians have been slower than the population at large to recognize what mental illness is, let alone what they should do.” Ed Stetzer, former president of Lifeway Research.
Unfortunately, current research confirms Christian churches aren’t (yet) very good at supporting those with mental health issues. And sadly, our experience is in line with the research: We’ve heard some pastors (though fewer and fewer every year) align psychiatry, psychology, and talk therapy with “witchcraft” or “sorcery,” blaming emotional instability on the presence of unconfessed sin, spiritual immaturity, a lack of discipline, or a character flaw. Their advice to the depressed and anxious, therefore, tends to sound like this: “Repent, pray more, read more Scripture, and engage in the spiritual disciplines.” We’ve even heard directly from church leaders that “real Christians don’t get depressed or anxious”— something about sin-guilt or a failure to grasp the redemptive power of God.
Pastor and author Frank Page explained the effects of our tendency to downplay and diminish mental illness in his book, Melissa: A Father’s Lesson From a Daughter’s Suicide:
We hear it sometimes stated in Christian circles that depression is a choice, that if you just snap out of it, talk yourself out of it, or pray yourself out of it, then you won’t have to deal with this. Or we hear that depression is nothing more than weakness, meaning that you simply need to snap out of it and get into a better way of positive thinking. While some of that may be true in some small degree, I think we have often used platitudes that fail to demonstrate a true understanding about what mental and emotional struggles are really like. And so I tell people to be very careful about your platitudes, since they can be hurtful, and they’re inadequate in almost every case.
Yet the majority of those suffering with a mental illness like depression or anxiety are hopeful and want church leaders to talk more openly about it. In truth, usually church leaders cannot offer effective support to the mentally ill because they don’t know how to help, not because they don’t want to help. LifeWay Research found that two-thirds of Protestant senior pastors seldom speak to their congregation about mental illness, but they don’t self-identify as “reluctant” to get involved with those suffering from acute mental illness. Pastors instead feel “overwhelmed” by it: “Pastors need more guidance and preparation for dealing with mental health crises. They often don’t have a plan to help individuals or families affected by mental illness, and miss opportunities to be the church… Pastors are trained for spiritual struggle. They’re not trained for mental illness.”
So take some time to talk to your pastor and find out what your church offers. If nothing is available, offer to work with the church and mental health experts to create a program that addresses all facets of the illness and properly equips church leaders to deal with mental illness. In doing so, you will be helping so many in your congregation get the spiritual and medical help they need.
How would I know if my teen suffers from either one?
Mood disorders often have physically, emotionally, and spiritually troubling symptoms. Depression and anxiety can occur separately or at the same time, sometimes triggering and cycling through one another. Children and teens can also show different symptoms than adults (e.g., a depressed teen may seem more irritable than sad), and every individual who suffers from these illnesses will find a unique explanation for it.
That said, if the following common symptoms of depressive disorders persist for more than two weeks, it’s probably time to seek professional help:
- Overwhelming feelings of sadness, restlessness, or apathy;
- Decreased interest in activities (especially ones that used to be enjoyable);
- Trouble eating and sleeping (either too much or too little);
- Physical complaints like headaches, stomach pain, or muscle soreness;
- Loss of energy or increased fatigue;
- Increased hand-wringing or pacing, or noticeably slowed movements and speech;
- Excessive feelings of worthlessness, guilt, hopelessness, inadequacy, or shame;
- Difficulty concentrating, focusing, or making decisions;
- Thoughts or statements of wanting to die (see our Parent’s Guide to Suicide & Self-Harm Prevention).
Anxiety disorders involve “persistent, excessive fear or worry in situations that are not necessarily threatening.” Teens often avoid situations that trigger or worsen their symptoms, which can include:
- Apprehension or dread that makes them change their plans or avoid places or people;
- Tension or jumpiness;
- Restlessness or irritability;
- Increased feelings of vigilance (anticipation of the worst, watching for danger signs);
- Pounding or racing heartbeat;
- Shortness of breath;
- Headaches;
- Trouble sleeping despite feeling fatigued;
- Upset stomach or even diarrhea; and/or
- Sweating or tremors.
Anxiety can also manifest as panic disorder (characterized by sudden feelings of terror sometimes mistaken for a heart attack), phobias (when an event, object, or place triggers a powerful, irrational fear response, and social anxiety disorder—not shyness, but an intense, irrational fear of social situations).
Other signs of mood disorders in teens may include academic difficulties, hostility or rage, rebellion, thoughts or threats of running away, hypersensitivity to failure or rejection, and trouble relating to others.
When prolonged and left untreated, these disorders can effectively numb the brain from all feeling as a protective measure. This makes it difficult to accomplish the smallest of tasks, like getting out of bed or maintaining personal hygiene. The most severe cases hinder concentration so that coherent thoughts are impossible.
What types of treatment are there?
Depression and anxiety can be effectively treated, and the earlier treatment begins, the better the prognosis: Quality of life can improve drastically in a fairly short time. Yet only about half of those diagnosed with major depression (including adults) ever receive any treatment for it, and even fewer receive good treatment. So rather than prolonging our teens’ misery, let’s help them by providing treatment that addresses all facets of the problem.
The value of prayer, study, meditation, etc. as one part of treatment cannot be overestimated, and unacknowledged sin, a weak relationship with God, brokenness, abuse, or trauma will all have negative consequences in one’s life. However, mental illnesses stem from neurochemical depletions and imbalances; these don’t respond to our will to fix them, no matter how hard we try. Besides, spiritual discipline requires concentration that often isn’t possible in the throes of a severe mood disorder. Telling a critically depressed person to “read more Scripture” or “pray harder” is like asking them to flip on a lamp with a burned-out bulb; it’s not going to light up, no matter how many times they try.
With that in mind, both faith leaders and parents shouldn’t try to diagnose, treat, or cure any illness, let alone mental illnesses. In addition, no single method of healing is a “one-size-fits-all” treatment, so what worked for one teen may not work for the next. This is important for us all to remember because an inappropriate spiritual rebuke can affect the life, and even the eternity, of someone fighting a debilitating emotional disorder.
Mood disorders can share symptoms with other illnesses, so only a healthcare professional with experience in treating child and adolescent mental illnesses can detect and treat these disorders properly. A complete psychiatric evaluation (including information about your child’s medical history, family history, age, social experience, and other factors) can narrow the possibilities and result in an accurate diagnosis and a more effective treatment plan, which may include the following options:
- Talk therapy to uncover and address unhealthy beliefs and thought-patterns; • Medications (especially when combined with talk therapy);
- Medical and psychiatric testing (including emotional inventories, physical exams, genetic testing, and others);
- Holistic approaches (such as lifestyle changes, training in self-care, or natural supplements);
- Inpatient, residential, or outpatient treatment programs, particularly if suicidal ideation or dangerous behavior persists;
- Meditation or mindfulness-based cognitive therapy, which studies are showing can be as effective in treating depression as medications; and/or
- In severe or prolonged cases, transcranial magnetic stimulation or electroconvulsive therapy (don’t worry—these treatments are nothing like One Flew Over the Cuckoo’s Nest anymore. Ask your doctor for an explanation).
Family and friends play a vital supporting role in your child’s treatment, management, and recovery from these illnesses. Family members may even accompany the teen to talk therapy sessions, attend group therapy sessions, or receive their own private therapy sessions, if deemed helpful.
The most important thing you can do: Effectively weigh the pros and cons of all treatment methods in partnership with a healthcare provider experienced in adolescent mental health and treatment. Talk to the doctor about how medication can specifically help your son/daughter, and don’t forget to tell the physician about other prescribed or over-the-counter medications your teen takes.
Christ Himself—although well-known for miraculous healings with just a word or a touch—employed a variety of techniques similar to treatment regimens, medicines, talk therapy, and other common methods of mental health care. Of course, He could have healed any way He pleased; His example shows how grace and individualized care leads to the wholeness He wants for us all (John 10:10).
How can I support my teen’s treatment?
1. Care for physical needs.
In 1 Kings, after a significant spiritual victory, Elijah collapsed under a tree and told God he was ready to die. God answered Elijah by first providing for his immediate, most basic needs: food, water, and rest. Renowned missionary Mother Teresa also focused first on the felt-needs of people, knowing each part of human wholeness—physical, mental, emotional, and spiritual—is indelibly linked to the other parts.
Even if a mental illness has damaged your kid’s physical health (poor eating habits, lack of sleep, poor hygiene, no motivation to exercise, etc.), encourage and even facilitate activity in their life. Agree with them that it’s difficult, but remind them how even a little activity can deflect symptoms and ward off an episode. You might even assign a loved one to account for the ill person physically from day to day. Just getting them out of the house for a while can do the trick.
2. Help them pray—and pray for them.
People with mood disorders often cannot manage praying for themselves. Although the Spirit will intercede for them in their inexpressible groaning (Romans 8:26–27), the intercession of the Body will put words to the often-inexplicable suffering and validate your teen and his/her illness. Encourage others who can protect the situation’s confidentiality to intercede in prayer, both in their own prayers and with your son/ daughter. Intercessory prayer will also offer support when the healing process stalls or hits a snag.
3. Encourage or assist them in accurately assessing the issue.
When wholehearted spiritual discipline does not alleviate symptoms, advise a visit to a qualified physician—not just any caregiver, but a specialist in adolescent behavioral illness. As mentioned earlier, mood disorders are actually very common and very treatable. If the specialist uncovers a related biological, lifestyle, or experiential matter, refocus your spiritual efforts appropriately and cheer them on as they continue in treatment.
4. Assure them of God’s truth.
People with mood disorders often forget what joy feels like. Their unmet expectations of life and what seems like a personal failure can arrest them with guilt and ruminating negative thoughts. Gently remind them of God’s love, grace, power, and promises, correcting any distorted beliefs and thwarting their mind’s destructive messaging. The Gospel is a story of something already “done,” not something we must “do,” and God’s truth is independent of our perception; that is, the truth is such not because of who hears it but because of Who declares it! A clear understanding of this removes our responsibility of being “good enough” or “holy enough” and allows rest in the One Who did it all (Matthew 11:28-30).
5. Be vulnerable.
Philosopher Jean Vanier said it best in his book Community and Growth: “I am struck by how sharing our weakness and difficulties is more nourishing to others than sharing our qualities and successes.” If you’ve ever struggled with depression, anxiety, suicidal thoughts, or anything that made you doubt God’s goodness, don’t hide that from your teen. Knowing you’re not alone and that someone else you care about has struggled or is struggling through this with you can make all the difference. Of course, share what you’ve learned and how it’s strengthened your faith and trust in God, too, not just the struggles you’ve had.
6. Give them specific steps to combat a serious episode.
Quality of life for the mentally ill can be cyclical with good days and bad days. Bad days occur unexpectedly and ruthlessly, with or without “triggers” or explanations. On a “good” day, provide a written list of spiritual helps for when bad days rear their nasty heads. You might list heartening Bible passages, words for prayer, God’s promises, names and phone numbers of supportive people to call, etc. Emphasize perseverance rather than achievement. A physical, written list—one they can see and touch— helps focus a racing mind and tangibly proves someone cares and support exists.
7. Minister to caregivers.
Families and loved ones can suffer greatly, particularly if they’ve had no (or poor) experiences with psychiatric care or mental illness themselves. They may feel out of control, angry, bitter, worried, burdened, impatient, helpless, or any number of complicated reactions. If your teen knows someone in trouble or if you know of a parent with a struggling teen themselves, provide support to them separately, ministering to their unique spiritual needs as you uncover them.
Don’t forget, dear parent, that you are a caregiver. You must not allow your compassion or actions on the behalf of your suffering son/daughter to drain you of your own personal wholeness. Acknowledge your own needs and boundaries as necessary and, like Elijah, allow your relationship with God and others to refill and renew you. Not only are you caring for yourself in stewardship of the vessel God gave you, it’s a good example to those who are watching (and healing).
8. Be patient.
Mental illnesses like mood disorders are treatable, but effective treatment can be a long, variable, complicated journey. Despite the high success rate of psychological treatment, the illness itself can affect the drive to seek help (it can feel safer to remain ill than to do the hard, unfamiliar work of getting better). Your teen can also get impatient and frustrated if he/she learns initial treatment choices need adjustment. While remembering to prioritize your self-care, pledge not to abandon your son/daughter on their road to wholeness. Repeat helpful biblical truths as many times as necessary (the illness can make things hard to remember). Perseverance will uncover all kinds of opportunities for spiritual growth in them and in you, and God will be glorified by them.
9. Refer crises or the critically ill to emergency care.
Some cases will be so severe or have gone untreated for so long, your assistance (and these suggestions) will not suffice. You might discover evidence that your son/daughter may be a danger to themselves or others. As terrifying as this idea is, parents must take all suggestions of self-harm, suicide, homicide, or unlawful acts very seriously. In these cases and for their sake, make safety a priority; call 911 and/or seek acute intervention immediately. A local inpatient behavioral treatment center, urgent care center, or hospital emergency room is best equipped to provide this help. If you really want to help more than just your son/daughter, go to your church’s pastor and ask him/her to keep information on local emergency care options handy and updated. Make sure your pastor knows which hospitals specialize in emotional crisis intervention, and suggest that the lay volunteer leaders be trained to contact the pastor immediately when they observe dangerous behavior or evidence of an emotional crisis in the church Body.
A final encouragement
When mood disorders like depression, anxiety, and other serious mental illnesses become manageable in a Christian who has long suffered, it is experienced as a holy deliverance from a very personal sort of pain. It activates a spiritual light that burns bright and won’t be extinguished by the failings of this fallen world. Their agony melts into a symphony of life inside people who once were desperate just to plink out a few notes of it. Author and pastor John Ortberg said it like this in his book, The Life You’ve Always Wanted: “Often it is the people closest to suffering who have the most powerful joy.”
With your help and a well-executed treatment program, your struggling teen can uncover incredible joy buried under these very real, very dangerous illnesses and reach the abundant life promised by Christ. It’s desperately needed, easier than you think, and so worth it.
“We need to be angels for each other, to give each other strength and consolation. Because only when we fully realize that the cup of life is not only a cup of sorrow but also a cup of joy will we be able to drink it.” — Henri Nouwen