From Coping To Conquering:
A Christian Psychiatrist’s View of the Relationship Between Physical Health and Depression, Stress, and Burnout
By Richard H. Steip, M.D.
What follows is an ongoing true story about a patient I am currently treating. His name and other facts have been slightly changed to assure confidentiality.
John, a 57-year-old married pastor with two children, is well respected and well known in our extended Christian community. People view him as an intelligent and successful church leader with a good marriage. A Christian counselor, who had been treating John for 2 months, referred him to me. The counselor wanted my psychiatric medical opinion on whether or not John needed medication. John was having diffuse burning sensations of his skin, severe anxiety, and a depressed mood. He also felt compelled to stay constantly busy, and whenever he felt underproductive he became even more anxious.
John told me he was on blood pressure and cholesterol-lowering medicine, did not smoke or drink alcohol, engaged in regular physical exercise, and had some osteoarthritis in his knee, probably from competitive sports earlier in his life. Except for a brief, mild reactive depression and grief after unfairly losing a pastorate 20 years earlier, and some transient periods of anxiety or tension during Christmas, he had never felt either this bad or this bad for so long. The anxiety he felt last Christmas had continued through May.
John also had reoccurring dreams of playing in a football game, being a star, then realizing the stadium was empty of spectators. He was experiencing greatly diminished joy and pleasure and would occasionally have bouts of crying. Prayer, healthy living, and exercise had not helped ease his 7 months of suffering.
A few months before seeking counseling, John had several nearly simultaneous stresses. His granddaughter had delicate surgery followed by a second corrective surgery. For a month he and his wife anguished over whether her breast lump biopsy was benign or malignant. One of his two adult daughters was diagnosed with an usually chronic severe psychiatric illness. Finally, he had been involved in two unsettling altercations with next-door neighbors, and he felt he had behaved and spoken in an angry manner unbefitting a pastor. This resulted in subsequent guilt.
John realized that part of his problem was internally driven. On top of his stresses, he had an exaggerated need for performance, productivity, and staying busy.
It was relevant that both of John’s parents were alcoholics. His father would get violent and his mother depressed. His father often traveled on business and, as he left, he would tell John, “You’re the man of the house while I’m away.”
John told me, “I was just 8 or 9 years old, and I grew up trying to make it happen and be ‘Mr. Responsible’.”
John agreed with my diagnosis that his persistent tension and anxiety, more so than depression, were the main issues at this point in his life. He agreed to try a mild tranquilizer and continued counseling.
After a couple doses of medication, John remarked that he was doing great and felt back to normal. He has continued to gain a better understanding of his past life experiences and self-expectations. He also has begun to address the simultaneous stresses that were overwhelming him in spite of his strong faith and grounding in the Word. Furthermore, he realizes that his exaggerated need for control was being overcome by feelings of vulnerability and failure that were creating more and more anxiety. For 2 months he has continued to improve with the use of minimal medication and by taking responsibly for his behaviors and thoughts. During this time, he has successfully ministered to others and served as husband, father, and grandfather.
The Relationship Between Physical Health And Depression
In general, there is an inverse relationship between health, depression, and stress and burnout. Healthy people tend to cope with, manage better, or conquer more easily the inevitable tribulations that accompany life. Unhealthy people do not, regardless of whether their ill health is a cause or effect of their problems.
Health is best defined as “soundness of body or mind” or “the general condition of the body and mind.” Health is synonymous with “vigor, vitality, strength, fitness, and stamina.”1 As implied in this definition, it is not wise to differentiate between physical and mental health, even though it is customary in our culture to do so. Physical and mental health are overlapping concepts and realities.
Depression may vary from major to minor, as do the various degrees in severity of burnout. Depression and burnout are best viewed as spectrum disorders. The symptoms of major depression can include: suicidal ideas, plans, or attempts; loss of ability to experience pleasure; lack of joy; sleep and appetite disturbances; and hopeless and helpless feelings. The symptoms of minor depression (dysthymia) include: sadness, discouragement, decreased pleasure and joy, and lesser disturbances in sleep and appetite. Both major and minor depression are commonly accompanied by physical complaints that may not have any medically diagnosable or observable basis.
Stress is defined as “a specific response by the body to a stimulus, such as fear or pain, that disturbs … the normal physiological equilibrium of an organism,” or “physical, mental, or emotional strain or tension.”2 Being overstressed implies suffering from a dynamic interaction of forces, either internal or external, in excess of one’s comfortable capacity to handle it. When stress continues to exceed one’s capacity to cope, manage, or conquer the stressor, burnout occurs.
Burnout is a failing or wearing out of one’s resources. Burnout is manifested by such symptoms as fatigue, apathy, irritability, temper outbursts, self-criticism, cynicism, and negativity. It also manifests itself when one feels continually besieged, overwhelmed, and helpless.
Symptoms of both clinical depression and burnout are headaches, digestive problems, weight gain or loss, and insomnia or oversleeping. Burnout often has an insidious onset and is often noticed first by one’s associates or family. Unrelieved burnout will lead to even more stress in one’s life such as job loss, drop in job performance, increased absenteeism, and illness.
In my case example, John was suffering primarily from overwhelming anxiety with associated minor depression, medically unexplained physical symptoms, and a decreased ability to enjoy life. His willingness to obtain counseling and psychiatric evaluation and to try medication is preventing burnout, major depression, physical illness, and loss of his ministry to his community and family.
The words we often use to describe our interactions with stress are telling. When we say we are burned out, are succumbing to stress, or we have become stressed out, we imply we have given way to or become ill or dysfunctional because of stress. If we are coping or dealing with stress, we are struggling with some degree of success and are persevering.
It is better to handle or manage stress, which means we are succeeding at accomplishing something or at least taking charge of the stressful situation. It is better yet to conquer stress. To conquer stress means we become a winner and are actively overcoming and mastering a situation. Best of all is the amazing, wonderful comfort that in and through Jesus Christ we are “more than conquerors” in our tribulations. God is with us, come whatever (Romans 8:37). All will be renewed and restored when we dwell with God eternally in a new heaven and earth with new, resurrected bodies (Revelation 21:1–7).
Tribulation, trouble, stress, adversity, or distress are inevitable results of living in this fallen world. If it were not so, Jesus would not have told us in John 16:33. But through Christ we can overcome and conquer.
Job, David, and Jesus expressed their stress in ways pastors can certainly understand and to which they can easily relate.
- “For sighing comes to me instead of food; my groans pour out like water” (Job 3:24).
- “A despairing man should have the devotion of his friends, even though he forsakes the fear of the Almighty” (Job 6:14).
- “Nights of misery have been assigned to me. When I lie down I think, ‘How long before I get up?’ The night drags on, and I toss till dawn” (Job 7:3,4).
- “My days … come to an end without hope” (Job 7:6).
- “I despise my own life” (Job 9:21).
- “My face is red with weeping” (Job 16:16).
- “My spirit is broken, my days are cut short, the grave awaits me” (Job 17:1).
- “I am faint; … my bones are in agony. My soul is in anguish” (Psalm 6:2,3).
- “How long must I wrestle with my thoughts and every day have sorrow in my heart?” (Psalm 13:2).
- “I am poured out like water, and all of my bones are out of joint. My heart has turned to wax; it has melted away within me. My strength is dried up” (Psalm 22:14,15).
Jesus, suffering the worst stress possible, bearing death on the Cross for the sin of the world, said: “My soul is overwhelmed with sorrow to the point of death” (Matthew 26:38).
Job, like many people who are overwhelmed with loss, depression, illness, and stress, expressed his feelings with sighing, appetite loss, groaning, despair, insomnia, hopelessness, wishing for death, crying, and brokenness. David expressed weakness, pain, anguish, despair, and exhaustion. Jesus, fully God and fully man, expressed overwhelming sorrow.
Medical Issues That Need to Be Addressed As a Possible Cause of Depression
There are many medical conditions that must be considered and treated, if necessary, to make sure they are not causing or exacerbating stress, depression, or burnout. The importance of regular medical checkups and a physical examination by a physician is important. Many pastors probably take better care of their automobiles than their bodies and minds.
The following is a brief list of some medical conditions that can easily be overlooked as a cause of depression:
- Diabetes (hyperglycemia) and low blood sugar (hypoglycemia) can cause poor concentration, mental dullness and confusion, jitteriness, irritability, excessive thirst or hunger, weight gain or loss, and excessive urination.
- Hyper- or hypothyroidism can cause sweating, heat or cold intolerance, hair and skin changes, anxiety or depression, heart palpitations, and weight gain or loss.
- Adrenal gland overactivity (Cushing’s disease) or underactivity (Addison’s disease) can cause weight gain, skin problems, high blood pressure, and severe mood problems.
- Disorders of the parathyroid glands (small glands behind the thyroid gland in the front of the neck) cause either high or low blood calcium levels that can affect muscle function and neurological irritability or lethargy.
These physical symptoms can cause depression if left untreated. These diseases often make the sufferer feel like a hypochondriac or cause others to accuse the sufferer of being one. People may feel they are causing or bringing these symptoms on themselves. Also, if a physician or the sufferer attributes all of the sufferer’s woes to medical conditions and its symptoms alone, underlying or resulting depression may be masked, overlooked, or ignored.
Other medical conditions commonly considered to be either psychosomatic or somatopsychic (mind affecting body or body affecting mind) include:
- Skin disorders such as acne flare-ups, eczema, psoriasis, hives, compulsive hair pulling (trichotillomania), patchy hair loss (alopecia), and skinpicking.
- Stress worsens asthma, gastric reflux disorder, irritable bowel syndrome, urinary urgency or constipation, and colitis.
- Menstrual and premenstrual disorders, libido and sexual arousal disorders, and erectile dysfunction.
- Tension and migraine headaches.
- Heart arrhythmias (irregular heart beats, palpitations) can result from stress.
These physical problems must be differentiated from serious underlying organ problems such as tumors or potentially fatal heart irregularities. Alcohol, illegal drugs, and abuse of prescription medications or caffeine can also mimic, cause, or worsen signs of stress, burnout, and some medical illnesses.
Many physicians today commonly see those suffering from what is diagnosed as Chronic Fatigue Syndrome and/or Fibromyalgia. Many psychiatrists believe this may be a modern term for what used to be called hysteria, neurasthenia, or hypochondriasis. Afari and Buchwald state: “Chronic fatigue syndrome is unlikely to be caused or maintained by a single agent. Findings to date suggest that physiological and psychological factors work together to predispose an individual to the illness, and to precipitate and perpetuate the illness. The assessment and treatment of chronic fatigue syndrome should be multidimensional and tailored to the needs of the individual patient.”3
The mechanisms by which unremitting and unrelieved stress affects our bodies are extremely complex. Acute and chronic stress mobilizes a fight-or-flight reaction in the sympathetic nervous system, raising blood pressure, heart rate, and breathing rate, while slowing down our digestive, reproductive, and immune systems. The clotting factors or chemicals in the blood increase, which are useful if a person is wounded in battle or by a predator, but harmful if they are unremitting. They are also capable of causing hardening of the arteries, clots in veins, and heart attacks and strokes. Physicians can order laboratory tests to check for stress and health-risk indicators such as blood lipids (cholesterol, HDL, LDL, and triglycerides), and some nervous system chemicals such as catecholamines (including epinephrine and norepinephrine), and blood or urinary cortisol elevations that indicate increased risk for heart attacks and strokes.
Midriff weight gain may be a high health-risk feature that is linked with heart disease, and may even be the body’s way to provide feedback to the brain and adrenal gland to decrease stress hormones.
Coping With Stress
There are many ways of coping with, managing, and conquering stress, depression, and burnout, and for maintaining health and aging well. Each person has different combinations of whats and hows to accomplish this. Everyone may not need counseling or medication to do well, but some will. The following recommendations and principles have been proven over the years.
- Get enough sleep. The average person needs at least 6 to 7 hours a night for adequate physical and mental energy restoration.
- Find an enjoyable exercise you can do regularly and persist in it.
- Keep your weight within healthy limits by eating reasonably balanced meals, avoiding high-sugar foods and foods high in saturated fats.
- Aggressively plan regular periods of rest including breaks during the workday as well as extended periods of rest, breaks in your routine, and at least two weeklong vacations per year.
Rest will not happen if pastors do not set aside time in advance by stubbornly insisting on it for themselves. I have recently, in addition to regular exercise, planned daily breaks for rest and change in routine. I fill these periods with thinking, prayer, reading, socializing, answering calls and e-mails, or enjoying exercise, fresh air, and sunshine. The rest is paying off. I am calmer and have had healthier blood pressure readings with less blood pressure medication than I was using a year ago.
Well-planned rest periods prevent things from piling up and lengthening our to-do lists. This also reduces stress. We enter the best rest of all — God’s rest — by abiding in Jesus (John 15:4; Philippians 4:4–7) and sharing our load and yoke with Him (Matthew 11:28–30).
- Nurture a social life and fellowship with other believers and nonbelievers regularly. God said: “It is not good for the man to be alone” (Genesis 2:18). This statement not only applies to one’s need for a spouse, but for regular fellowship with others as well. We must “spur one another on,” “not give up meeting together,” and “encourage one another” (Hebrews 10:24,25).
Family-oriented and socially adept people tend to age better and be healthier. Isolation and loneliness sickens and kills. Pastors need to focus on the people who should be the closest to them, those who really matter, and not neglect their parents, spouses, and children in their relentless pursuit of projects, things, power, money, or control.
- Develop a positive attitude and have a sense of humor. Immerse yourself in Bible studies about hope and overcoming through Christ. If a pastor was raised by negative parents, he may need counseling to restructure his thinking and cognitive assumptions.
- Get a sense of control by getting help and information, delegating, avoiding positions with too much responsibility, and avoiding vulnerability relative to adequate power and control over situations at hand. Responsibility without control creates excess stress and illness.
- Lighten your load by eliminating the excess and unnecessary, whether it is inappropriate responsibility, unneeded material things or things that cause financial stress, bad relationships, or unhealthy habits and appetites that are sinful and hinder your relationship with Christ. Overcommitment of your time, even to good causes like ministry, can spread you too thin and cause burnout. Even jettisoning unhealthy concepts (like John, in my case example, having to be “Mr. Responsible”) will lighten your load.
Pastors often pursue wise and healthy biblical living, yet they continue to suffer. John had a healthy relationship with Christ. Yet, even with Christian, Bible-based counseling, he still suffered terribly for over 7 months. Rather than being like Job’s friends who searched endlessly for some unrepented or yet undiscovered sin to explain why John was not improving, and make him worse in the process, his counselor wisely referred him for further professional evaluation. In John’s case, it was a psychiatrist. With proper medication along with counseling, John experienced a quick and favorable outcome for his anxiety.
When we understand church leaders may not be skilled enough to help, it is time to seek additional help through licensed professional counselors such as social workers, marriage and family counselors, psychologists, and psychiatrists. Proverbs 11:14 says, “Where there is no counsel, the people fall; But in the multitude of counselors there is safety” (NKJV, emphasis mine).4
Some Christians recoil at the suggestion that they might need to visit a mental health professional. Perhaps these Christians still relate mental health professionals to early 1900’s Freudian atheism. An empathic, properly trained therapist, however, can be used by God to help and heal. Of course, whenever possible, it is preferable to have a Christian counselor who uses the Word of God in counseling. In many areas of the United States it may be difficult to find Christian psychiatrists or psychologists. God can still use a nonbelieving counselor. Good therapists are trained listeners for what comes out of our hearts. In this sense, all counselors are heart surgeons. A good therapist knows the power of the tongue to heal, bless, curse, or hurt.
A pastor must use wisdom in picking a good therapist. “The wisdom that comes from heaven is first of all pure; then peace-loving, considerate, submissive, full of mercy and good fruit, impartial and sincere” (James 3:17). When searching for a therapist, look for those traits.
Medication may be needed when symptoms are severe enough to:
- interfere with a person’s daily performance at work or at home.
- affect a person’s sleep, appetite, digestion, and energy.
- cause physical illnesses that complicate a person’s problems.
- cause physical symptoms that keep a person distracted.
- cause a person to consistently visit doctors or the emergency room.
- render a person a potential danger to others through suicidal behaviors or irritability leading to violence.
Psychiatrists are the best-trained professionals to administer psychotropic medications. People also need a psychiatrist who takes time to listen to the patient and to the patient’s family and friends. The psychiatrist also needs to communicate with referring counselors and other physicians.
When seeking a psychiatrist, find one who is skilled in psychopharmacology and is continually learning about the newest and safest medications. While family physicians, internists, and gynecologists are capable of prescribing medication, they rarely have the time, training, or experience to prescribe psychiatric medications as skillfully as psychiatrists.
Psychiatrists have many medications from which to choose to help their patients’ recoveries or stabilization. Medications work by altering or stabilizing different nervous system chemicals, nerve cells, or tracts. So far, the most is known about serotonin, norepinephrine, dopamine, and gamma-aminobutyric acid. But psychiatrists are only scratching the surface of an extremely complex interwoven system of brain chemicals. Antidepressants and most tranquilizers work on one or more of these.
Lithium and several anticonvulsants use different ways to calm nerve cells. Lithium helps cyclic mood disorders. Anticonvulsants can also help chronic pain, headaches, and appetite regulation. By altering how the brain’s chemicals are transmitted from nerve to nerve, by calming irritable or excited nerve cells, or by allowing these substances to accumulate more in the space between nerve cells, these medications alter mood, excitability, irritability, and escalating or impulsive emotions and behaviors. They can also have alerting and concentration-enhancing effects, enhance sleep, and normalize the hunger drive. By improving the physical body in these ways, people who are suffering from chemical/neurological imbalances are better able to return to normal or better functioning and feeling. It is truly both art and science to choose the right medication(s) for any individual, maximizing therapeutic benefits while minimizing side effects or adverse interactions with other drugs the patient might also be taking.
I have presented some key concepts in how physical health, stress, depression and burnout interact, some practical things pastors can do to maximize health and successful living, as well as some steps they can take to get help in recovering from the ill-effects of stress, burnout, and depression. I trust that, although what I have written represents only my opinion and not that of all of organized psychiatry or medicine, I have provided reasoned advice that comes from decades of training and education and experience in the private practice of psychiatry seasoned with the Word of God.
1. Random House Webster Unabridged Dictionary, second ed., (N.Y.: Random House, 1998).
3. Afari and Buchwald, “Chronic Fatigue Syndrome: A Review,” American Journal of Psychiatry 160 (2003): 221–236.
4. Scripture quotations marked “NKJV” are taken from the New King James Version. Copyright Â© 1982 by Thomas Nelson, Inc. Used by permission. All rights reserved.