John Kirkwood attended Oklahoma State University College of Osteopathic Medicine. He completed a residency in Family Practice at Scott & White in Temple, Texas. He has been married to Joy Langford for 30 years. They currently live in Pasadena, Texas. We have three beautiful children-Kelli, Beau and Kindsey.

January 23, 2006 started out as a typical day just like any other. Little did we know that it would end as a very tragic day for the Kirkwood family. It was on this day, that our brother, Michael David Kirkwood, committed suicide. At this time we were a family of three brothers and a nephew working together as family physicians with our brother Mike serving as our office manager.

My brother Ron and I saw Mike on this morning. He looked impeccable and professional as he always dressed to the nines. Since we had some business that we needed to discuss after lunch, we went into his office and told him that we would like to meet with him once we returned. Mike acknowledged to us that there were many things that needed to be done because we were in transition with a major hospital corporation. He looked very upbeat, was smiling, and gave no appearance that anything was wrong. The important lesson we later learned is not to judge a book by its cover. Of course we had known that Mike had problems with depression, but we thought he had been doing well. Little did we know that he had not been taking his medication. Upon returning from lunch, we received a phone call that Mike had been involved in a tragic situation. We immediately went out searching the town looking for him. Shortly, we found his truck, but the police would not allow us to come close to the vehicle. We had the deep-sinking feeling that we knew what the end result would be, and it was shortly confirmed that he had taken his life. Receiving this news, it is impossible to describe the multitude of emotions experienced. We unwillingly became part of a fraternity of people who have lost loved ones to suicide as a result of anxiety and depression.

As news of his death spread, people came to our sides to provide comfort. This is when we learned just how many others had also suffered from events like this one. Later we discovered, that like most, Mike had written a letter to his family. This confirmed to us that he had contemplated this horrendous act, and disguised it so well that no one knew that he was capable of it.

Depression and anxiety are extremely common. As a family physician, I see this every day in my clinical practice. There are astounding numbers of people who actually suffer from this condition that go without being evaluated or treated. This is due to a negative stigma often associated with anxiety and depression. People are afraid that they may be considered crazy or psychotic. They are afraid to tell others that they are seeking professional help due to lack of trust and the negative response that may be directed at them. For example, a patient of mine who received the necessary medication to treat her depression showed great improvement. This aroused suspicion in her husband, who questioned her if something was going on outside their relationship. Upon discovery that she had sought professional help for depression, he vehemently refused for her to continue to take medication or come back to the clinic. She had a tearful last visit at my office, despite the fact that the medication had made her feel better than she had in twenty years. This example illustrates that this stigma can restrict the patient's desire or ability to come in to be evaluated. Quite often a depressed person instead seeks help from others such as friends, family, spouses, and co-workers. With this help, some people are able to effectively learn coping mechanisms and how to deal with symptoms. Unfortunately though, I have heard stories of people telling someone that they just need to snap out of it, get over it, or deal with it. It is never that easy, and a depressed person's symptoms and behavior should never be trivialized. Hopefully, the depressed person will be encouraged to seek treatment, especially when behavior escalates to the point where it is pathological or destructive. I have even seen cases where symptoms have gone untreated for years, and a patient finally seeks help due to an inability to cope or be productive.

A further discussion of depression and anxiety now necessitates identifying the basic types, causes, symptoms, and treatment.

Types of Depression

There are many types of depression ranging from mild to severe. A milder form can manifest itself as anhedonia which is the inability to experience pleasure from activities usually found enjoyable such as exercising, hobbies, music, and social interactions. The severe form of depression is known as major depressive disorder (MDD). With this wide range of symptoms, it is my job to diagnose why a patient is tired, fatigued, or just doesn't feel right. I must determine how the symptoms should be treated. It should also be noted that there is almost no family that I have seen that has not had a member diagnosed with some form of depression and anxiety, including my own.

This brings me back to the point that the ugly side of major depression is suicidal behavior. There are many factors that are believed to increase risk, and patients must be closely observed and monitored. Some of the risk factors are high levels of anxiety, lack of social support, stressful ongoing life events, family discord and divorce, burden of medical diseases and serious conditions, history of previous suicidal attempts, and rehearsal of a plan. It should be noted that even though women statistically have more attempts at suicide, men are more aggressive in nature in their attempts and more like to commit suicide. Sadly, in 2013, there were greater than 41,000 people in the United States who died from committing suicide.

Causes of Depression

There is no specific causation for depression and anxiety although there are many theories to its etiology. One theory is a neurotransmitter disorder. A great deal of research has gone into trying to discern how CNS (central nervous system) pathology patients suffer due to neurotransmitter issues. There is also a strong genetic link that is believed to be a contributor to depression. Other things that can play an important role are hormonal or medical conditions, as well as specific events that have occurred in relationships. Depression can also arise from economic hardships and when a person's life is out of balance.

Symptoms of Depression

The symptoms of depression can have catastrophic effects in work, social, personal, and spiritual relationships. For example, in a spiritual situation, depression may cause a loss of zeal and an inability to worship and pray as before. Here is a list of symptoms that medical students and doctors are trained to look for:

Change in appearance
Lack of care in hygiene or disheveled appearance
Weight gain (binging) or
Weight loss (loss of desire to eat)
Psychomotor problems
Irritability
Diminished interest or pleasure in activities
Sleep disturbance (insomnia or hyperinsomnia)
Mental fog or inability to concentrate/focus
Work or daily living routine impaired
Inability to make good decisions
Sadness
Lack of interest in life
Headaches, gastrointestinal disorders and musculo-skeletal complaints
Feelings of loneliness
Feelings of helplessness

One of the most important symptoms is that regardless of living and working with numerous family and friends, a person may complain of an emptiness that is difficult to describe. It is my job to let them know that they are not alone. At least two-thirds of patients do not even realize that they have depression and will look with distain on the diagnosis. No one wants to have depression or anxiety, but lifetime prevalence of incidence of depression is extremely high. Statistically, females suffer more from depression than men. It is estimated that 20% of women and 12% of men will suffer at some point from depression. This increases with age, and is more likely depending on certain medical illnesses. There are also patterns of hormonal, seasonal, and chronic medical condition flare-up depression.

Some Types of Anxiety

General Anxiety Disorder
Social Anxiety Disorder
Phobias
Separation Anxiety

Anxiety is more than just being an excessive worrier. It can get to the point where it is pathological, destructive, and dysfunctional. The patient's clinical manifestations depend on which type of anxiety is being experienced. Anxiety, like depression, is thought to be from a mechanism of the central nervous system where there are some neurotransmitters that are not properly functioning. There may either be too much or a lack of epinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Medications have been and are being developed to try to help with these types of neurotransmitter conditions.

Causes of Anxiety

Prescription medicine
Genetics
Relationships
Over the counter medications/herbs/stimulants

Like depression, more women tend to suffer from anxiety than men.

Syptoms of Anxiety

Palpitations (heart pounding or racing)
Fidgety behavior
Irritability
Unexplained shortness of breath
Lightheaded/dizzy
Feeling of impending doom
Fear of dying

Often patients are seeking a medical explanation for symptoms that are actually caused from anxiety. It is true that there are cardiopulmonary and endocrinology diagnoses that can be contributable to anxiety so it is prudent for a patient to be treated for any underlying medical conditions. At times, a good thorough neurological examination is also warranted.

The Good News

In the Bible, we know that there were those who suffered from depression. The word "depression" was sometimes depicted using terminology such as downcast, downhearted, forlorn, sad, mourning, troubled, miserable, and broken-hearted. The book of Job gives us some depiction of depression and how Job dealt with catastrophic events in his life. This book shows us that Job was able to overcome losing everything dear to him through his love for God. Another book dealing with depression is the book of Jonah. With God's help, Jonah was able to persevere through his despair. God was also able to help Elijah by giving him the strength to overcome when Elijah asked God to let him die (1 Kings 19:4). The Psalm of David, in Chapters 42 and 43, shows that even "a man after God's own heart" suffered from feelings of depression. Other biblical examples of despair include Hannah (1 Sam. 1-2) and Abraham (Gen. 15) who both sought solace from God when unable to bear children.

With the Bible in mind, one of the main reasons that I went into medicine was not only to help those who were having physical or psychological hardships, but to help others in their spiritual life. I am cognizant every day that some people believe in the power of the pill and want a quick fix. It is my preference that they seek to have a balanced life that includes a strong spiritual component. Sometimes patients look at me humorously when I tell them, "What's wrong with good diet, healthy exercise, low stress, sleep management, and a happy spiritual life?" Sometimes that just seems too simple. First and foremost they need to know that God knows when we are hurting. He has promised us that he is there to help us. He will guide us in our lives and we can walk with Him and talk with Him through prayer. Like anything else this requires strong discipline and it is easy to fall off track and not ask for help. That is why Paul has given us strong words of encouragement in dealing with great trials and tribulations in 2 Corinthians 4:8-9 - "We are troubled on every side, yet not distressed; we are perplexed, but not in despair; Persecuted, but not forsaken; cast down, but not destroyed." Paul has blessed us through his example of strength in difficult encounters.

Treatment

As stated, depression and anxiety are experienced by many. Unfortunately this can at times lead to catastrophic and life-changing situations. Some of the current treatments available consist of support from family, friends, co-workers, group therapy, and learning about self-awareness. Other interventions include keeping a composite of ongoing signs and symptoms, cognitive and behavioral therapy, psychotherapy, and prescriptions. Most patients want to get better and need motivation to do so. I strongly encourage everyone to get out of a sense of loneliness and helplessness by being active in serving others instead of focusing on how bad they feel. We sometimes have unrealistic ideas of what peace and happiness are really all about and our "on the go" society causes us to feel tired and fatigued. In fact, I am teaching the medical students in my clinic that the symptom of fatigue is quickly becoming the number one reason patients are seeking medical attention over the current reason of low back pain.

We have only one life to live and we need to live it to its fullest in a productive and healthy way. We should all be aware that depression and anxiety are catastrophic to patients and those around them. As concerned Christians, it is our responsibility to help those in need. If someone you know is showing signs and symptoms of depression and anxiety, encourage him or her to seek medical attention. A significant number may benefit from medication(s), and ALL can benefit from the healing words of the Lord in the Bible.

"I waited patiently for the Lord; and he inclined to me, and heard my cry. He brought me up out of the pit of destruction, out of the miry clay; and he set my feet upon a rock, making my footsteps firm. And he put a new song in my mouth, a song of praise to our God. Many will see and fear, and will trust in the Lord" (Psa. 40:1-3).

"I can do all things through Him who strengthens me" (Phil. 4:13).