[혁신적연구] Listening to Prozac . . . and to the Scriptures: A Primer on Psychoactive Medications

Listening to Prozac . . .and to the Scriptures: A Primeron Psychoactive Medications

by Michael R. Emlet

What Do You Hear?

You’ve been working for six months with acounselee who struggles with serious depressionand anxiety. After walking alongside her in hersuffering, you have together identified ways inwhich her perfectionism and her mistrust inthe goodness and mercy of the Lord contributeto her anxiety and depression. She is slowlymaking progress. You see her more consistentlyusing the Psalms to move toward God to voiceher fears and disappointments. She is lesshypercritical of herself and others. Then, over aone-month period, you see remarkable change.It’s like she’s coming out of hibernation. Sheshakes off her sluggish spirituality before youreyes. The Word comes alive to her in new andfresh ways. She has a growing excitement toserve others. Her depression and anxiety lessenweek by week. You rejoice! And then she tellsyou that four weeks earlier she saw her primaryphysician who prescribed Prozac, which shehas been taking since.

So, how do you view her change now? Areyou disappointed? Thankful? Confused? Do youchange your counseling approach? Shouldyou be more proactive in recommending anevaluation for medication, particularly for those

counselees who seem “stuck” or are making___________________________________________Michael R. Emlet (M.Div., M.D.) counsels and teaches atCCEF and directs CCEF’s School of Biblical Counseling.He is the author of “Crosstalk: Where Life and ScriptureMeet.”

slow progress? Do you prayerfully considergoing to medical school so you, too, canprescribe Prozac?!

Another counselee comes to you forhelp with longstanding obsessions andcompulsions. He has been on six differentmedication combinations in the past, none ofwhich have significantly improved his struggle.He is discouraged about his lack of progressand about the twenty pound weight gainand frequent headaches he has experiencedover the last six months on his latest medicalregimen. Where do you begin?

A counselee notes on his intake form thathe is taking Tegretol, Zoloft, and Abilify for adiagnosis of bipolar disorder. He is interested incoming off these medications and wants youradvice before he returns to his psychiatrist. Morespecifically, he has developed the convictionthat he should, with God’s help, be able to livemedication-free. How should you proceed?What information would you want to know?Should a life characterized by robust faith andrepentance make medication unnecessary?

These vignettes show that familiaritywith psychoactive medications is a must forcounselors. We live in a time when more andmore problems in living are attributed to brain-based dysfunction. Medication is touted as animportant (if not the most important) aspect oftreatment within the psychiatric community. Inpopular street-level understanding, it is THE

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treatment of choice.
Christians remain divided on this issue.

Some would say that medication is usuallyappropriate, viewing it as a “common-grace”tool to relieve mental suffering. Others aremore cautious, recommending medication onlyin more severe situations. Still others decrythe use of psychoactive medication as a “cop-out,” when a basic posture of gospel-centeredobedience is all that is really necessary.

As Christians, we can’t just “listen toProzac”;1 we need a biblically-based philosophyto guide the use or non-use of medications. Weneed to know not only the “what” and “how” of

psychoactive medication use, but also the“why”or “why not.” And we need strategies. Howshould we proceed in difficult cases like thosementioned above?

To that end, I have several goals in thisarticle:

•  to familiarize you with the basic classes ofpsychoactive medications,

•  to review what we know about themechanism of action and efficacy of suchdrugs, and

•  to discuss a biblical approach to psychoactivemedications.

  Classes of Psychoactive Medications

  The term“psychoactive”medication refersto those chemical substances that are designedto enter the brain tissue from the bloodstreamto cause changes in mood, thoughts, emotions,and behavior.2 Most any medication, at highenough doses, can have psychoactive (side)effects (e.g., a certain high blood pressure pillmay cause drowsiness or impaired ability toconcentrate). But my focus is on those classesof medications designed to have effects on thebrain.3

  Let me summarize the various classes here.

  Antidepressants – are probably the classof medications we are most familiar with.Early antidepressants, developed in the 1950sand 60s, such as Tofranil (imipramine) andElavil (amitriptyline), are still used today, buthave been overshadowed by the “SSRIs”—

selective serotonin reuptake inhibitors—suchas Prozac (fluoxetine), Zoloft (sertraline),Paxil (paroxetine), and Celexa (citalopram),which were released in the late 1980s.Other antidepressants with varied chemicalcompositions include Wellbutrin (buproprion),Effexor (venalafaxine), Remeron (mirtazapine),and Cymbalta (duloxetine). No one sub-classof antidepressants has proved more effectivethan another and newer antidepressants arenot more efficacious than older ones, althoughthey do tend to have less sedative side effectsthan the older antidepressants.

Mood Stabilizers – are used to treat bipolar

disorder. These are also called “anti-maniadrugs.” Lithium, discovered in 1949, has beenthe gold standard within psychiatry for manyyears. But it is associated with potentiallydangerous side effects, so it is less likely to beused as a first-line agent unless the personhas a more severe presentation. More likelyare medications that initially were used forseizure disorders but were observed to have amood-leveling effect. These include Tegretol(carbamazepine), Depakote (divalproex) andLamictal (lamotrigine), to name a few.

Antiobsessionals – are medications usedto treat obsessions and compulsions. Manyof these are the SSRIs I noted earlier, alongwith Anafranil (chomipramine). Notice thatmany medications, particularly the SSRIs,have multiple potential uses authorized by theFood and Drug Administration (FDA). Rightaway that tells you that these medicationsare less like “smart bombs” that work withlaser precision, and more like conventionalbombs with widespread effect on systemsof neurotransmitters in the brain. This lackof specificity reminds us just how little weunderstand the neurobiological component inpsychiatric problems.

Psychostimulants – have been used sincethe 1950s to treat the symptoms of Attention-Deficit Hyperactivity Disorder (ADHD). Theseinclude Ritalin(methylphenidate),Concerta(thesustained release version of methylphenidate),Focalin (dexmethylphenidate), Dexedrine

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(dextroamphetamine), and Adderall (mixedamphetamines). Because they are stimulantsthey have the potential for abuse if not used asprescribed.

Antipsychotics – are used to treat thesymptoms of psychosis, including thehallucinations and delusions characteristicof schizophrenia. The older antipsychotics,used since the 1950s, include Thorazine(chlorpromazine), Mellaril (thioridazine), andHaldol (haloperidol). Due to very severe sideeffects, some of which are permanent, thesedrugs were limited in their use.

However, the creation of a new generation

Table 1

Anxiolytics (anti-anxiety medications) –are used to treat the symptoms of anxiety.Historically, physicians have used a subclassknown as benzodiazepines for treating anxietyand panic. These included drugs such as Valium(diazepam) and Librium (chlordiazepoxide),and more recently, Klonopin (clonazepam),Ativan (lorazepam), and Xanax (alprazolam).

The problem with the benzodiazepines,when used regularly and over the long term,is the potential for tolerance, dependence,and withdrawal. Tolerance means that yourbody requires more of the drug over time toget the same effect. Dependence is your body

Classes of Psychoactive Medications

*Many of these drugs are available as generics. Basic drug information is available at www.PsyD-fx.com

of antipsychotics has led to more patients beingtreated, particularly bipolar patients whosemania has features of psychosis. These newerantipsychotics, which are essentially equal inefficacy to the first generation antipsychotics,include Risperdal (risperidone), Zyprexa(olanzapine), Geodon (ziprasidone), and Abilify(aripiprazole). Early research suggested thesecond-generation antipsychotics had fewerside effects. More recent research suggests thepotential for equally serious but different kindsof side effects when compared to the first-generation antipsychotics.4

saying it needs a certain level of the drug to feelnormal and to prevent withdrawal. Withdrawalsymptoms, including increased anxiety, rapidheart rate, sweating, and more, occur when thedrug is stopped abruptly due to this physicaldependence. In some cases this withdrawal(e.g., from Xanax) can be life-threatening. Ingeneral, physicians now use benzodiazepinesfor the short-term treatment of anxiety, andare more likely to prescribe the SSRI class forlonger-term treatment.

Hypnotics – are prescribed for insomnia.Older agents were in the benzodiazepine class

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but now physicians choose newer drugs suchas Ambien (zolpidem), Sonata (zaleplon),Lunesta (eszopiclone), and others that haveless addictive potential.

Although I mentioned some specificconcerns above, it is important to note that sideeffects are common with each of these classesof psychoactive medications. Drowsinessand weight gain are very common. Sexualside effects, such as decreased libido and theinability to experience orgasm, may be as highas 60% in the SSRI sub-class. As we will seelater, the potential benefits of using medicationmight outweigh the costs, including side effects;so simply note at this point that these are notbenign agents. They may help, but they can alsoharm—hence their regulation by the FDA!

Do Medications Treat a “Chemical Imbalance”?

Now that I have familiarized you with thebasic categories of psychoactive medications,let’s tackle the question,“How do they work?”Are they treating “chemical imbalances”?This is certainly the lay understanding, asfueled by biologically-oriented psychiatryand pharmacological marketing. But dopsychoactive drugs correct imbalances in bodychemistry?

To answer that question, I need to give youa crash course in basic neuro-anatomy. Don’tworry, if you were an English major, I’ll makeit painless! In the brain there are billions ofnerve cells (neurons) that communicate witheach other via chemical substances calledneurotransmitters. In simple terms, the sendingcell releases neurotransmitters into the spacebetween it and the receiving cell. The receivingcell has receptors for the neurotransmitter andis activated when the neurotransmitter binds toit. Following activation, the neurotransmitter isreleased from the receptor site. Then it either:1) is taken back up into the sending cell tobe repackaged and used again, 2) remainsin the space between the neurons, or 3) getsdestroyed. Scientists have discovered over200 neurotransmitters. Some that you may befamiliar with are serotonin, dopamine, andnorepinephrine. The theory is that psychiatricproblems result from an imbalance in, or adysregulation of, neurotransmitters in certainparts of the brain. For example, some concludethat depression results from a deficiency

of serotonin, so treatment involves usingpsychoactive medications to address thisdeficiency. The impact of these treatments isoften vividly portrayed in pharmaceutical adsin before and after schematics of the patients’brains. But what do we really know?

First, since we are unable to measureneurotransmitter levels in the brain of a personbeing treated with these medications, wecannot scientifically prove that these drugs areresponsible for any changes in the person’ssymptoms. Note that this is very differentfrom other medical diagnoses. For example,for hypothyroidism we can directly measure alow amount of thyroid hormone, or for diabeteswe can directly measure a high amount ofglucose in the bloodstream. Treatment ofboth conditions will lead to direct changes inblood measurements. But because we cannotmeasure neurotransmitters, we cannot makethe same kinds of conclusions about the impactof the psychoactive medication on the person’ssymptoms.

Second, we do not know exactly howthese medications work in humans. What wedo know is how these medications work in testtubes with animal brain tissue and this researchis then extrapolated to humans. This, in and ofitself, is appropriate for testing hypotheses, butit cannot tell you what is actually going on in thehuman brain. Listen to what even a very bio-medically-oriented scientist, pharmacologistStephen Stahl, has to say:

In general, contemporary knowledge ofCNS [Central Nervous System] disordersis in fact largely predicated on knowinghow drugs act on disease symptoms, andthen inferring pathophysiology [i.e., what’swrong physically in the brain] by knowinghow the drugs act. Thus, pathophysiology isinferred rather than proved [emphasis mine],since we do not yet know the primaryenzyme, receptor, or genetic deficiencyin any given psychiatric or neurologicaldisorder.5

Here is an example from the description ofa specific drug. The PDR (Physician’s DrugReference) describes Zoloft (sertraline) thisway: “the mechanism of action of sertralineis presumed [emphasis mine] to be linkedto its inhibition of CNS neuronal uptake ofserotonin.”6

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In other words, Zoloft may impact theneurotransmitter serotonin in the human brainas it does in basic laboratory research, but we’renot certain. Nor are we exactly sure how thismight translate to an antidepressant effect.

This is important: if neuroscientific andpsychiatric researchers acknowledge thecurrent limitations of biomedical hypothesesregarding the origin of psychiatric symptoms,how much more should we as biblicalcounselors acknowledge the complex nature ofthese struggles, taking into account underlyingspiritual, biological, relational, situational, andsocietal-cultural factors! 7

So, at best we can say these drugs modulate,or change, neurotransmission in some way,and that seems to be associated with symptomreduction in a statistically significant proportionof those tested in clinical drug trials. But, arethese drugs treating a chemical imbalance?We don’t really know—maybe. We know theyseem to alleviate symptoms in some people butdo not exactly know how. Our knowledge isincomplete. However, by pointing out that thelevel of actual knowledge we have about howthese drugs work in the brain is limited, I’m notsaying we should avoid such medications. I’msaying that if we do use them, we should beaware of what we really know. We have muchto learn and a cautious optimism is in order, notan unbridled and uncritical enthusiasm.

How Effective Are Psychoactive Medications?

Space precludes an analysis of each classof psychoactive medications, so let me focusprimarily on the use of antidepressants sinceit is the class you will encounter the mostfrequently. First, remember that a drug cannotcome to market unless the FDA approves it,based upon the results of clinical drug trials.More specifically, a study medication has tobeat a placebo by a statistically significantmargin to be considered effective.

So, how well do antidepressants work?Compared to placebo they have been shown in

published studies to help in mild, moderate, andsevere depression. Realize that the “placeboeffect” in clinical studies is not uncommonly35% and even higher. This shows the powerof belief: if I think a treatment I’m receivingmay be effective (whether it is or is not) it ismore likely to have that effect. The higher theplacebo effect, the more the active drug mustdemonstrate its effect in order to be consideredsuperior to the placebo.

Take for example a clinical drug trial of200 depressed patients, 100 of whom receive anew antidepressant and 100 of whom receivea placebo. The standard protocol for such

studies is “double blind”—i.e., neither thepatients nor the researchers know who has theactive medication vs. the placebo, so as not tobias the results.8 Let’s say 35% of the placebogroup responds favorably with reduction oftheir depression (= the placebo effect) and 70%of the active drug group responds favorably.Looks good, right? But remember a componentof that 70% could be the power of belief (aplacebo effect of the active drug) and anothercomponent could be the actual biochemicaleffects of the drug itself. So, at the end of the day,of those 100 patients who got the active drug,30% did not respond, 35% may have respondedby virtue of a standard placebo effect, and 35%may have responded due to the actual effectsof the drug itself.9 We should conclude thatoverall there seems to be a modest drug effect,but it’s certainly not a “chemical cure.” Andthese studies ultimately say nothing about howan individual person will or will not respondwhen given an antidepressant. At this pointthere is no way to predict who will respond bestto which treatment.

We can also ask if medications are moreeffective than counseling 10 for depression.Individual studies have revealed thateven in moderate to severe depression,although medication might bring more rapidimprovement compared with counseling,counseling was equal to medication at four

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months of treatment. Note that the degreeof effectiveness of the psychotherapy maywell depend on the counselor’s experience/expertise.11 There is also evidence that cognitivetherapy is superior to medication in preventingrelapse once medication and/or counselingis discontinued.12 Other studies seem toshow that the combination of counseling andmedication may be superior to counseling ormedication alone.

It is important to remember that notall psychiatric symptoms are created equal.I have been highlighting treatment fordepression, which is quite variegated in itspresentation. Other problems, such as thepsychotic symptoms of schizophrenia or, insome cases, the mania of bipolar disorder,definitely respond better to medication than tocounseling. However, a multi-faceted approachthat includes counseling and other socialinterventions is still in order once psychosis hasstabilized.

So, what should we conclude from allthis information, particularly with regard toantidepressants? They do seem to work—thatis, improve mood and other symptoms ofdepression—in some people, some of the time,but they certainly are not the “silver bullet”that some make them out to be.13 Even if weconclude that medications are or might beeffective for a particular person, they compriseonly a part of the total approach to the person.Secular research shows the critical importanceand efficacy of psychotherapy as well.

Medications may well changeneurotransmission at microscopic levels;they certainly are associated with change inthe pattern of brain activity at “macroscopic”levels on “live action” brain scans such aspositron emission tomography (PET scans) andfunctional MRIs (fMRIs). But then secular formsof counseling such as cognitive behavioraltherapy have “proven effective” as well.14 Inthat sense, both medication and counseling are“biological”treatments—medication directly so,and counseling indirectly so. How much moreso should we expect brain activity patterns tochange with the embrace and actualization ofgospel-centered counsel!

A Biblical Evaluation

We have assessed the secular data onthe use of medications, but how should we

assess the use of medications from a biblicalperspective? First, remember that we exist asbody-spirit creatures. We are simultaneouslybody and soul. There’s never a time we’re notspiritually engaged. And there’s never a timewe are not bodily engaged. This means thatattention to both physical and spiritual aspectsof our personhood is mandatory in ministry.What biblical-theological truths provideguidance? Let me discuss some things I keepin mind as I consider the use of medications.15You might call this “walking the wisdom tightrope” because you will see that the biblicalapproach balances different priorities.

It is a kingdom agenda to relieve oursuffering; it is a kingdom agenda to redeem usthrough suffering.

When the kingdom comes in JesusChrist, you see God’s heart with regard tosuffering in two ways. First, it is God’s designto relieve the suffering that arose as a resultof the fall. Consider how Mark 1 describes theactivities of Jesus’ministry: teaching, exorcisms,healing those with various diseases, prayer,and cleansing a leper. Peter put it this way toCornelius:

God anointed Jesus of Nazareth with theHoly Spirit and power, and . . . he wentaround doing good and healing all thosewho were under the power of the devil,because God was with him. (Acts 10:38)

Clearly a mark of the in-breaking kingdom isrelief of suffering. Relief of suffering is a goodthing! As the Puritan Jeremiah Burroughssays, contentment is “not opposed to all lawfulseeking for help in different circumstances, norendeavoring simply to be delivered out of presentafflictions by the use of lawful means.”16 I believemedications can certainly be one of thoselawful means.

You see a second strand of teaching in theNew Testament: God’s design to redeem theexperience of suffering for believers because oftheir union with Jesus, the Suffering Servant.Paul calls this “the fellowship of sharing in[Jesus’] sufferings” (Phil 3:10). By virtue ofbeing in Christ, God is at work in the midst ofour suffering, conforming us to the image ofChrist. This is the very gateway to experiencinghis resurrection power and glory (cf. Phil 3:10-11; Rom 8:17; 2 Cor 4; 2 Cor 1:8-9; 1 Peter 4:12-13; James 1:2-4). So, while relieving suffering is

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a kingdom priority, seeking mere relief withouta vision for God’s transforming agenda in themidst of suffering may short-circuit all thatGod wants to do in the person’s life. Anotherway of saying this is we should be glad forsymptom relief but simultaneously look forthe variegated fruit of the Spirit: perseverancein the midst of suffering, deeper trust in theFather’s love, more settled hope, love for fellowstrugglers, gratitude, and more.

Medications are a gift of God’s grace;medications can be used idolatrously.

I believe it is right to view the developmentof psychoactive medications as a good gift fromGod. As such, we should receive them gratefullyand humbly, not forgetting who has given thenecessary wisdom to scientists and physiciansto discover such remedies. He is the One whopromises to uphold you with his righteous righthand (Isa 41:10).

Sadly however, I have met people whoare better evangelists for Prozac than theyare for the living God. Rather than viewingmedication as simply one component of a full-orbed God-centered treatment approach, theyview it in almost salvific terms. By definition,this is idolatry: investing ultimate power andhelp in something other than our triune God.If a counselee believes that what really mattersis fine-tuning the dose of Paxil, and findsdiscussion of spiritual things superfluous orirrelevant, that’s a problem. How the personresponds when the medication works—ordoesn’t work—reveals the basic heart posturebefore God. Thanksgiving and a more ferventseeking after God in the wake of medicationsuccess says one thing; a lack of gratitudeand a comfort-driven forgetfulness of Godsays another. A commitment to trust God’sfaithfulness and goodness in the wake ofmedication failure says one thing; a bitter,complaining distrust of his ways says another.

Too much suffering can be “hazardous”to spiritual growth; too little suffering may be“hazardous” to spiritual growth.

This might be considered a corollary tomy first point. What do I mean here? Simplythis: in the midst of intense suffering, whetherit stems from the body or from other sources(relationships, life circumstances), there tendsto be a greater temptation to become embittered

and angry. Witness the counsel of Job’s wife,“Curse God and die” (Job 2:9). As we’ve seen,it’s not a bad thing to seek deliverance fromintense suffering; the psalmists ask for it all thetime in the midst of their grief.

At the same time, a lack of suffering maybring the temptation to simply forget that “inhim we live and move and have our being”(Acts 17:28). This was part of the problemGod’s people experienced once they enteredthe Promised Land; their dependence on himwaned in the midst of material blessing (Deut8:10-14; Judg 2:10-12).

Here’s another way of saying this: God-centered contentment is elusive in want orin plenty. Neither situation is the “ideal” forspiritual growth. Paul highlights this in Phil4:11-13. He learned “the secret of being contentin any and every situation, whether well fed orhungry, whether living in plenty or in want.”Helooked to the strength of Christ in all situations.So, don’t be too quick to cast off suffering asthough immediate relief from trials is the onlygood God is up to. And don’t think it’s more“spiritual”to refrain from taking medications, asthough character refinement through sufferingis the only good God is up to. We don’t chooseour suffering in some masochistic way; yet weare called to a life of walking in the footstepsof our suffering Savior. Christ teaches us acruciform and dependent lifestyle.

A person can have wrong motives for wantingto take medication; a person can have wrongmotives for not wanting to take medication.

Often, the most important issue in the useof medications is the attitude of the personto whom you are ministering. It’s not thatpsychoactive medications in themselves areeither “good”or “bad.”Rather, it’s how a personviews and handles this potential treatment thatmakes the difference. I’ve had counselees whowant a referral for medication immediatelywithout really wanting to examine their heartsand lifestyle. I’ve had counselees who resistthe recommendation to consider the use ofmedications for self-oriented reasons. Let meelaborate on these two scenarios.

What are problematic reasons for wantingto take medication? The first is a demand forimmediate relief coupled with doubt aboutthe benefits of looking at potential underlyingissues. I remember meeting one time with a

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young man who came in with a recent history ofanxiety associated with public speaking. Someof the things he said pointed to underlyingfear of man/fear of failure—much to workwith from a gospel perspective! But he was notinterested in counseling. He was not interestedin a gospel perspective on his struggle. Rather,he had made an appointment for the solepurpose of obtaining my recommendation fora provider who could prescribe an anti-anxietymedication.

A second questionable motive for wantingto take medication involves caving into thepressures of others. Family and friends (and

counselors!) may push for medications due totheir own discomfort in seeing the suffering oftheir loved one. Sometimes the pressure reflectsa selfish desire to have their loved one back tonormal so that life would be easier for them.

What problematic reasons exist for notwanting to take medication? Resistance tomedication can be an issue of pride and self-sufficiency: “I should be able to do this withoutmedication. ” Or the more spiritualized versionof this: “I should be able, by trusting God more,to do this without medication. ”Another reasoncould be fear of man: “What would peoplethink? ”Yet another concern is shame: “There’ssomething seriously wrong with me if I have totake this medication.”

Many people sincerely want to grow inChrist in the midst of their mental sufferingand simply wonder about the pros and consof medication. Many rightfully wonder aboutthe potential side effects of using medication.These thoughtful counselees remain open tostarting—or not starting—medication, which isa wise posture before the Lord.

Using medications may make it more difficultto address moral-spiritual issues; not usingmedications may make it more difficult to addressmoral-spiritual issues.

Scripture treats us as unified beings, havingboth spiritual and bodily aspects.17 Given thatwe are fully integrated, body and spirit (heart/soul) creatures, it is not surprising that bodily

strength or weakness impact us spiritually andvice versa, but I’ll focus here on the impact ofour bodily constitution on our spiritual lives.

Here’s a simple example. Let’s say thatfor various reasons outside your control youhave had poor sleep for the last week. You’reexhausted; you find it difficult to concentrate.You also find that you are more prone togrumbling and impatience. You see life througha grey lens. And then you get two great nightsof sleep in a row. Suddenly, your world issunnier.You have a new vitality, both physicallyand spiritually. Patience and kindness requirefar less effort. What just happened? A physical

“treatment”—sleep—impacted your spirituallife. The heart issues of grumbling and irritationhave become less prominent. That’s notnecessarily a bad thing; we are called to be wisestewards of our bodies. But in a time of“plenty”(sleep-wise), we shouldn’t forget our sinfultendencies toward anger and complaining thatwere revealed in our weakness. At the sametime, we don’t “invite” greater bodily stressso as to provoke our own hearts! This is ourFather’s business,“mingling toil with peace andrest.”18

How does this relate to the use of psychotropicmedications? Improving someone’s symptoms (ofanxiety, for example) doesn’t necessarily addressthe underlying fears and desires that may bepresent. Might one feel better? Yes. Again, thismay not be a bad thing in itself, but does theperson retain the zeal to address the revealedheart inclinations now that those propensitiesare less visible in day-to-day life? Is there acommitment to address the situational factorsthat contribute to the experience of anxiety?In my experience, more mature believers doindeed remember what they saw in the mirrorand continue to take their soul to task inthought, word, and deed (James 1:23-25). Theydo recognize the importance of assessing andchanging contextual factors. But I have also hadcounselees who, after improvement in theirsymptoms, assume no further work is required.

Conversely, there are situations, albeitmore extreme, when a failure to use medication

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may make it more difficult to address a person’sspiritual life. I counseled a young woman in ademanding graduate program who presentedwith insomnia, depression, severe anxiety, andsuicidal thoughts. While her suicidal thoughtsrapidly waned by simply airing them with me,her other struggles did not. She could affirmintellectually the promises of God, but it waslike her soul was coated in Teflon; the truths ofScripture seemed to slide right off. While thisdisconnect is true for all of us to some degreeit seemed particularly prominent for her.

After several weeks, I saw how much herongoing exhaustion from the insomnia waspart of a vicious cycle. On the one hand, youcould say that her insomnia, which was anxietydriven, was a fruit of her fear and unbelief andso that should be the primary target of ministry.On the other hand, you could say that herbodily exhaustion was making it much moredifficult for her to respond in a faith-filled way.Both are appropriate avenues for ministry. Inthe end I thought that evaluation for a short-term course of sleeping medication mightbe beneficial to break the negative cycle shewas in. In fact, that was the case. As she sleptbetter, it wasn’t as if her problems magicallymelted away; she still struggled with anxiety.But she was able to internalize spiritualrealities and truly begin to engage with God,addressing issues of perfectionism, legalism,and fear of man, which were root causes of heranxiety and despair.

Think of it this way: using medicationin select situations may be analogous tocalming the surface waters to allow fordeep-sea exploration. You can’t have a divingexpedition if there is a gale on the surface ofthe water. Situations in which such “calming”might be helpful include (but are notnecessarily limited to) the hallucinations anddelusions of psychosis (whether associatedwith schizophrenia or mania) and severe orunremitting anxiety or depression, particularlyif associated with suicidal thoughts andplans.19

Can taking a medication actually assistin sanctification? Yes, in the same way thatadequate sleep can assist in sanctification!It’s not that you can buy holiness in a pill, butusing medication in certain situations mayhelp set bodily conditions that allow for a

greater spiritual flourishing.

Putting It All Together

What have we seen? The scientific witnessis mixed. While psychoactive medicationsmay help a certain percentage of individuals,the benefits do not rise to the level touted bypharmaceutical companies. In addition, thesemedications are associated with significant sideeffects. In depression, working with a trainedcounselor is at least as effective as medicationand may confer a longer-term protectionagainst relapse. Biblically we have seen thatgospel-centered ministry targets both thesomatic and moral-spiritual aspects of life, andthat both relief of suffering and perseverance inthe midst of suffering are consistent with God’sdesign. We also noted the interdependenceof body and spirit. Given these scientific andbiblical perspectives, what should our practicein counseling be with regard to psychoactivemedications?

I hope you have seen there is not a clear-cut “right” or “wrong” answer. There is nouniversal “rule” we can apply to all people atall times. There is no simple algorithm. Rather,the use of these medications is a wisdom issue,to be addressed individually with counselees.There will always be a mix of pros and cons,costs and benefits to carefully consider. Wemust ask,“What seems wisest for this particularperson with these particular struggles at thisparticular time?” Most often, addressing theperson’s suffering and sin takes place withoutthe use of medication.Yet, in some cases, afterasking that question, we will lean toward moredirectly addressing potential bodily causesand correlates of the person’s struggle byrecommending an evaluation to consider theuse of medication. Notice how I phrase that—“recommending an evaluation to consider...”I’m not mandating. I’m not making a definitiverecommendation. I’m simply suggesting thatmedication be considered as a part of theholistic approach to the struggle.

I’m most likely to recommend anevaluation for medication when any of thefollowing occur:

symptoms are severe and unremitting,
symptomsarenotabatingdespiteengagement

withthecounseling process,orthere is a high risk of suicide.20

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I encourage you to develop a relationshipwith a trusted and wise psychiatrist whoshares your strong biblical convictions and isable to provide consultation for these kinds ofdecisions. Such a person may or may not existin your locale. Well-trained, clinically-savvypsychiatrists whose practice is governed by arobust biblical worldview are indeed few and farbetween! A family physician or internist withextensive experience in the use of psychoactivemedications may be another option. The pointis that we biblical counselors don’t make thesedecisions on our own; close communicationwith medical providers is essential.

Often enough, people come to me alreadyon medications and the choice to start or notstart them is a non-issue.21 Usually they’verealized that medications do not solve all theirproblems. They need help to reconcile conflict,or to walk in faith not fear, or to address anyof the multitudes of other problems thatbring people to counseling. There’s plenty todiscuss apart from talking about the utility ornon-utility of their medication. Whether onmedications or off, the goal is always to help aperson grow in love for God and for neighbor.

Let me illustrate with an orthopedicanalogy. I liken the use of medications to theuse of crutches, and I don’t mean that in apejorative sense. A person can experience manydifferent injuries to the legs that don’t require aset of crutches. He may have visible pain; hemay have a limp initially, but the problem isself-limited with forms of treatment other thanthe support of crutches. Here I might think ofmilder experiences of depression, anxiety, andOCD, for example, where medication (like thecrutches) might not be needed.

Others require crutches to assist themafter experiencing a more significant injury orsurgery. They use them for a season while theirbodies recover. Here I might envision a fairlysevere postpartum depression or severe panicattacks treated by a brief course of medication.Still others have a more significant disabilityand may need to use crutches for an extendedtime or perhaps for life, if the disability ispermanent. Here I think of problems such asschizophrenia and severe bipolar disorder,which seem to have a more significant brain-based etiology and long-term use of medicationseems warranted.22

Then, there are times someone maybe relying too much on his crutches and itactually impedes progress. I experiencedthis as a teenager when I broke my ankle.After the cast was removed I was told to bearweight ‘as tolerated.’ But I didn’t tolerate itvery well! I continued to use my crutches foran extended time because putting weight onmy ankle caused pain. At my follow-up visit,my orthopedist told me to throw away thecrutches and learn to bear weight, despite thepain. It was hard work, but I learned again towalk without the aid of crutches. The bottomline is that all musculoskeletal problems aredifferent and it takes wisdom to know whenthe additional support of crutches is necessaryand, if so, for how long. The same is true ofpsychoactive medication.

The analogy is imperfect, of course. It’seasier to determine if someone can walkunaided or not. It’s far more challenging toassess what a person can or can’t do in themidst of emotional suffering. We see througha glass far more darkly than we realize. We willalways struggle to find a wise balance betweenattention to the spiritual and physical aspects ofour personhood. Sometimes in retrospect we’lljudge that we should have recommended thepossibility of medications earlier. Other timeswe will conclude that we jumped the gun andthat medication wasn’t the wisest choice afterall. But we can be sure that whether medicationis part of the total ministry approach ornot, God sovereignly acts, and “is able to doimmeasurably more than all we ask or imagine,according to his power that is at work within us”(Eph 3:20). He will accomplish the redemptionthat he has begun in us.

To conclude, let’s return to the openingexamples and see how this“wisdom”frameworkmight look in action. What about the womanexperiencing depression and anxiety? Certainlywe should rejoice in the remarkable changes inher life! But can we say why she has changed?No doubt the Prozac could be having brain-based biochemical effects that have catalyzedher spiritual growth, given the mysteriousinterface of body and spirit. Or she could beexperiencing a placebo effect from the Prozac.Or the Prozac isn’t really doing much, butGod has himself intervened in his providentialtiming in a new and deeper way. At the end

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of the day, I remain unsure about the ultimatecause. But my goals would be the same for her:rooting her security in Christ’s righteousnessin a way that pushes against her perfectionism,turning to God as an ever-present help in themidst of anxiety, and moving outward in lovetoward others. I wouldn’t make a huge issueof the medication right now, although I mightinquire about her decision to see her primaryphysician. Did she feel that progress was tooslow? Did family or friends urge her to go?What is her understanding about the utility ofthe Prozac?

At some point in the future, shouldher spiritual growth be sustained and herdepression and anxiety remain at bay, I wouldsuggest her physician consider discontinuingher medication.23 It’s not that the ultimategoal is being off medication—conformity tothe image of Jesus Christ is! But there’s noindication at this point, by virtue of severity orchronicity of her struggle, that she would needto be on medication long-term. In fact, theprogress (albeit slow) she was making prior tothe medication bolsters that hope.

The second counselee is experiencing thereality that medication is not a panacea forhis obsessions and compulsions. For him, notonly has medication not helped, its side effectshave hurt him. While I’m dubious about thebenefit of continuing his medical regimen, Iwould not recommend that he discontinue themedication(s) on his own. Instead, I wouldsuggest he speak with his physician aboutsuspending the medication temporarily andsee how he fares. If I were concerned aboutthe quality and experience of his treatingphysician, I might recommend a consultationwith a trusted psychiatrist. But apart from anydecisions about medication, there is muchwork to be done in addressing his obsessionsand compulsions from a gospel-centeredframework.

Lastly, how would I approach the manwho has the bipolar diagnosis and wants todiscontinue his medications? I want to get abetter idea about the nature of his struggle overtime. When was he diagnosed? How severewere his symptoms? Did he have psychoticfeatures? Has he had recurrences either onmedication or off medication in the past? Howcompliant has he been with his medications?

Has he ever been hospitalized? The moresevere and recurrent his problem—and here Imight get input from his family and friends—the greater the concern I would have aboutdiscontinuing medication.

In addition, I want to understand why hebelieves God wants him to be medication-free.24How has he come to that decision? If the manchooses to discontinue his medications he willneed close monitoring and follow up. I wouldwant to work closely with his psychiatrist, aswell as with other members of his family andchurch community.

Some Concluding Thoughts

We are body-spirit creatures. We shouldnot be surprised that a physical treatmentsuch as medication may be associated withsymptomatic and perhaps more substantialchange in people’s lives. Medication can bean appropriate and even necessary part ofsomeone’s care, depending on the specificnature of a person’s struggle.

Yet, we must admit a great deal ofremaining mystery about how psychoactivemedications actually work in the humanbrain. We take care to remain balanced in ourassessment of the efficacy of medications.We neither exalt them nor disregard them.Even if we do view medication as a potentialpiece in a comprehensive ministry approach,we always seek to bring the riches of Christ’sredemption to bear upon people’s lives. Sinnerswill always need mercy, grace, forgiveness, andsupernatural power to love God and neighbor.Sufferers will always need comfort, hope, andthe will to persevere. Ultimately, these blessingsare found not in a pill bottle...but in the personof Jesus Christ.

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1 See Peter D. Kramer, Listening to Prozac (New York:Penguin Books, 1993).
2 The adjectives “psychotropic” or “psychiatric” aresynonyms for psychoactive. These terms can be usedinterchangeably.
3 A helpful, fairly comprehensive (and compact)resource is John Preston’s “Quick Reference Guide toPsychotropic Medication,”found at www.PsyD-fx.com.4 See J.A. Lieberman, et al.,“Effectiveness of antipsychoticdrugs in patients with chronic schizophrenia,” NewEngland Journal of Medicine, 353:12 (2005): 1209-23.
5 Stephen M. Stahl, Essential Psychopharmacology:Neuroscientific Basis and Practical Applications, 2nd ed.

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(Cambridge: Cambridge University Press, 2000), 104.6 Physician’s Desk Reference, 59th edition (Montvale:Thomson PDR, 2005), 2681.
7 The ongoing disagreement within psychiatry itselfregarding how to understand and classify mentaldisorders shows the insufficiency of a purely biologicalorientation to causation and treatment of psychiatricsymptoms.

8 If I know I am getting a placebo—an inactivesubstitute—I will be less likely to respond favorably;the placebo effect declines. If I know I am getting theactive drug, it is more likely to work; that is, the placeboeffect (even for the active drug) is boosted.“Blinding”thestudy participants seeks to avoid this bias. Of course, if Iexperience side effects because I am on the active drug,I may conclude that I am taking the study medication,which also biases in favor of the drug.

9 Some, like Irving Kirsch, argue that most, if not all,of the favorable response to the drug is an enhancedor boosted placebo effect. (See Kirsch, The Emperor’sNew Drugs: Exploding the Antidepressant Myth[New York: Basic Books, 2010]). For a rebuttal, seeFrederic M. Quitkin, et al., “Validity of Clinical Trials ofAntidepressants,” American Journal of Psychiatry, 157:3(2000): 327-337.

10 Cognitive or cognitive-behavioral therapy is the mostfrequently studied method of counseling.
11 R.J. DeRubeis, et al., “Cognitive therapy vs.medications in the treatment of moderate to severedepression,” Archives of General Psychiatry 62 (2005):409-416.

12 S. D. Hollon, et al., “Prevention of relapse followingcognitive therapy versus medication in moderate tosevere depression,” Archives of General Psychiatry 62(2005): 417-422. See also Robert J. DeRubeis, Greg J.Siegle, and Steven D. Hollon, “Cognitive Therapy VersusMedications for Depression: Treatment Outcomes andNeural Mechanisms,” Nature Reviews Neuro-Science 10(2008): 788-796.

13 As believers we hope not only for symptom reductionbut also for tangible growth in love for God and love forpeople. Improved mood may correlate with these things,but not necessarily!

14 Robert J. DeRubeis, Greg J. Siegle, and StevenD. Hollon, “Cognitive therapy vs. medicationsfor depression: Treatment outcomes and neuralmechanisms,” Nature Reviews Neuro-Science 10 (2008):788-796.

15 I could look at the places in Scripture whereattention to the body is explicitly mentioned as a focusof“treatment”—e.g., passages include 1 Kings 19 (God

“prescribed” sleep, food, and water for Elijah) and 1Timothy 5:23 (Paul urged Timothy to take some wine forhis stomach ailment). However, it is my assumption thatthe doctrines of creation, incarnation, and resurrection(among others) demonstrate the critical value God placesupon our bodily constitution. Therefore, my startingpresupposition is that the body is an appropriate“target”for ministry, just as our moral-spiritual dispositionclearly is. So my focus will lie on other aspects of biblicaltruth that inform the use or non-use of medications forthe Christian.

16 Jeremiah Burroughs, The Rare Jewel of ChristianContentment (Carlisle: The Banner of Truth Trust, 1964), 22.17 For an extensive treatment of biblical anthropology,see John Cooper, Body, Soul, and Life Everlasting: BiblicalAnthropology and the Monism-Dualism Debate (GrandRapids: Eerdmans, 2000). For a briefer summary, seeEdward T. Welch, Blame it on the Brain? DistinguishingChemical Imbalances, Brain Disorders, and Disobedience(Phillipsburg: P & R, 1998) and Michael R. Emlet,“Understanding the Influences on the Human Heart,”Journal of Biblical Counseling, 20:2 (2002): 47-52.

18 Carolina Sandell Berg,“Day by Day and with EachPassing Moment,”Hymn #676, Trinity Hymnal (Atlanta:Great Commission Publications, 1990).
19 These extreme cases are more clear-cut. But we livea culture that doesn’t tolerate any hint of “rough seas”but yearns for the comfort of glassy calm waters. Thiscontributes to the overuse of psychoactive medication insome who only want a quick fix rather than tasting thefruit of persevering through choppy waters.

20 My goal with a seriously suicidal person is tostabilize the person first, with medications or even withhospitalization if necessary, then begin to work throughthe particular problems in living.

21 This is generally because they have seen their primarycare physician who has prescribed such a medication,but they may have already seen a psychiatrist as well.The majority of psychoactive medications—particularlyantidepressants—are prescribed by primary carephysicians.

22 Understanding the causes and classification of mentaldisorders is another topic in itself, although closelyrelated to the subject at hand. The trajectory of modernpsychiatry has been toward the biological, fueled in partby the apparent success of psychoactive medications.Thus, diagnosis and treatment go hand-in-hand.

23 Most psychiatrists recommend a 9-12 month courseof an antidepressant before discontinuing it.
24 A new onset of “super-spirituality” may in fact be awarning sign of mania!

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