A term paper submitted November 14, 2021 to Dr. David Shackelford (EN7900) as a requirement for my MDiv at Mid-America Baptist Theological Seminary
The journey of modern man is within his mind. Where once wild forests and uncharted mountains tempted brave explorers, the modern man, restless, looks within himself and often grows more so. To conquer the giants in their minds, men have turned to psychiatry.
Throughout its short history, psychiatry has promised many outcomes. Its proponents continue to uphold historical claims while pharmaceutical companies still vie against one another to release the flashiest drugs and the most advertisable treatments.
In depression, some have found one such mighty giant. Psychiatry posits their solution. The antidepressant will best treat this darkness of the mind. Indeed, Psychiatry has done an excellent job making inroads into cultural thought through academic work and convincing advertisement. The CDC reported that “13.2% of Americans aged 18 and over reported taking antidepressant medication in the past 30 days”51 between 2015 and 2018.
Advocacy groups, medical groups, pharmaceutical companies, and even famous actors and actresses have fought to break the negative stigma that taking antidepressants has historically carried. Some church leaders have also tried to break this stigma in recent years, suggesting the mental and emotional benefits of antidepressants for those whose depression is enduring or inhabilitating.
How should believers view antidepressants in light of Biblical sufficiency? Should antidepressants ever be considered in the process of Biblical sanctification? Is depression purely physical and therefore needing a doctor’s prescription, or is depression spiritual? If depression is at least partly spiritual, are there solutions in Scripture for fighting this very real problem in the lives of so many people?
Christian doctrine and a study of psychological evidence find that antidepressant medication, while not useless, falls far short of a promised cure for the average depressed person compared to Biblical guidance on inner-man struggles. This paper does not seek to convince anyone that antidepressants are entirely without advantages, nor is it the object of this study to convince the reader to skip his medication without consulting a medical professional and seeking advice from a spiritual counselor. Instead, this study aims to give Christians a balanced approach towards antidepressants, which looks to the Bible as the ultimate source of aid in fighting any spiritual problem, not medication.
To accomplish a balanced Biblical approach, this study will briefly analyze psychiatry’s history and current footprint. Claims and practices associated with medicinally treating depression will also be discussed. The second section will critique these claims and practices. Early psychiatric advocates made grand claims about their field of research. Modern pharmaceutical companies tout their medications as the end-all-be-all of cures for depression. How do these authoritative claims hold up against evidence? For the Christian, how do these claims stack up against the Word of God? Lastly, a Biblical view of sanctification, authority, and depression will be presented, exploring how antidepressants might or might not fit into God’s plan for the individual believer.
State of Psychiatry and Antidepressants
As it is known today, the study of psychiatry grew heavily during the 1970s and into the 1980s. Within this period, Psychiatry became heavily influenced by a purely biological approach to treating man’s mental and societal woes.52 As doctors began prescribing mind-altering drugs more frequently, scientists sought more earnestly for the physical source of the medicinal effect of psychoactive treatments. Notions of a soul or spirit were seen as fantastical and ignorant.
Drugs would be the cure for modern man’s societal, emotional, and mental woes. A miracle of science was birthed: pills of all types to solve the darkest issues of people’s minds. With this promise to communicate to the public, pharmaceutical companies began mass-marketing this cure. Subsequently, these companies grew increasingly wealthy,53 able to pour more money into the research and development of these life-changing pills. During this time, when psychiatry seemingly had the cure for several mental illnesses, the broader academic world began to take notice.54
A Biological Model
A group of psychiatrists, medical academicians, and other scientists began forming a new model for inner struggles. This “medical model” posited that all disorders have a fundamentally physical root and should be treated by physical methods.55 Mental disorders, such as depression or anxiety, are as foundationally biological as “cancer, muscular dystrophy, or heart disease.”56
In the 1970s and 1980s, psychiatrists began to presume depression “to be caused by faulty biochemistry—a ‘chemical imbalance.’ By common consensus, it also became the ‘common cold’ of psychiatry.”57 Fueled by this biological understanding, popular writers began propagating ideas of “chemical imbalance” as the root of depression to the public.58
Terms such as “mental illness” and “mental disorder” began to take a firm hold on popular culture. After all, if the mind is purely biological (it can get sick), and these issues are merely mind issues, why not refer to them as mental illnesses? Indeed, noted psychiatrist and Nobel laureate Eric Kandel reduces all psychiatric behavioral problems to faulty biological functions, “…behavioral disorders that characterize psychiatric illness are disturbances of brain function, even in those cases where the causes of the disturbances are clearly environmental in origin.”59
A Medical Issue
These ideas led to the medicalization of so-called mental disorders, such as depression. Peter Conrad defines medicalization as “a process by which nonmedical problems become defined and treated as medical problems.”60 Modern psychiatrists and prescribing physicians who follow “biological reductionism”61 normally prescribe drugs alone in treating previously nonmedical issues. A study published by the Public Library of Science supports this fact. The study surveyed depressed patients’ experiences with the diagnosis and prescription process and found “that doctors are less willing to consider nondrug treatments if drug therapy is available.”62 The study contained a particularly disturbing excerpt of one patient’s experience, “I do not like taking pills and told this to the doctor. Then she prescribed Valium so I would feel more relaxed in taking Seroxat.”63
With approximately 16% of the population having suffered from major depression at some point in their lives, researchers consider major depression the most common mental disorder of the modern age.64 Consequently, the current method of treating depression is such a vivid illustration of the medicalization Conrad defines. For example, the American Psychiatric Association (APA) recommends antidepressants, not only as the first line of defense against depression but also as “continuation therapy (approximately 4-9 months) and maintenance therapy (several years up to an indefinite time).”65
As previously discussed, researchers theorized depression to be caused by chemical imbalances. Antidepressants are supposed to stabilize these chemicals to provide a balance in the brain’s “monoamine neurotransmitters.”66 This theory was termed the monoamine hypothesis.67 Historically, people have faced deep feelings of dread and darkness in response to stress or grief. With the advent of antidepressants and the medicalization of depression, it became unseemly for the modern man to suffer from depression. After all, without a soul, there must be some biological malfunction behind dark feelings. And if depression is purely physical, it can and should be cured with a drug.68
Today, depression is still a reality in the lives of millions. While scientists and pharmaceutical companies continue to pour billions of dollars into research and development, depression diagnoses increase. A study by the WHO found that depression would be the leading cause of worldwide disability by 2020, overshadowed only by ischemic heart disease. This rise is substantial considering that depression was only the fourth leading cause of global disability fifteen years ago.69
Critique of Psychiatry and Antidepressants
The passage of time and lack of evidence has caused severe distrust among practitioners for psychiatry’s claims of a final cure for depression. Hengartner expresses these doubts succinctly, “However, paradoxically the massive increase in antidepressant prescription rates over the last three decades did not translate into measurable public health benefits. From a public mental health perspective, we would expect that effective antidepressants reduce the prevalence and burden of MD, [major depression] unless the scientific evidence is unreliable.”70
Within the past few decades, scientists have also begun to break down the claims of the monoamine hypothesis. The idea of a chemical imbalance as the cause of depression is at the least disputed,71 and at the worst, incomplete, simplistic, and obsolete.72 The Public Library of Science study cited earlier reads, “… it is argued that there is no scientifically established ideal of a ‘chemical balance’ of serotonin, let alone an identifiable pathological imbalance.”73 As to a replacement for the chemical imbalance theory, there is a shortage of understanding about depression, with practitioners admitting that “there is probably not a simple relationship between biogenic amines and depression postulated by classical monoamine hypothesis…. the current picture of the pathophysiology of depression is largely incomplete.”74
One must then ask, how effective are antidepressants really? Dr. Irving Kirsch experimented with this question in his book The Emperor’s New Drugs. Through a comprehensive metanalysis of both published and unpublished studies on the comparison of antidepressants to placebos, Kirsch found that the medicinal effectiveness of antidepressants was shockingly low on average. The most positive change found in depressed patients was due to the placebo effect of the drugs,
It must be stated that Kirsch did find that antidepressants were more medicinally effective for severe depression at significantly higher doses than typically prescribed.76
Kirsch is not an outlier. In Hengartner’s critique of psychiatry and some of its flaws, he asserts that “the pooled efficacy of antidepressants is weak and below the threshold of minimally clinically important.”77 Lee claims that antidepressants are only “effective in less than 50% of patients.”78 Another author even went so far as to suggest that doctors should consider not prescribing antidepressants to those “with mild complaints who are not convinced of their efficacy.”79 A noted Biblical counselor, Edward Welch, points out that a physician must prescribe the drug when a patient receives an antidepressant. Physicians are highly respected in our culture, and the respect of their position can cause the patient to believe in the drug’s effectiveness, making the medication more effective. He posits that if pharmacies sold antidepressants over the counter, they might not have the same effect.80
Kirsch also found that antidepressant side effects increased the subjects’ perceptions of efficacy. As subjects experienced side effects they knew were connected with the prescribed drugs, they associated the side effects with the effectiveness of the antidepressant. Subjects felt the drugs were ‘working’ merely because they were experiencing side effects. Studies that compared antidepressants to active placebos (drugs that are not antidepressants but with similar side effects) rather than inert placebos found that the differences between the antidepressant and placebo were not “statistically significant.”81 In connection with this finding, a study seeking why patients skip their antidepressants (which is extremely common) found that experiencing side effects surprisingly did not cause patients to stop medicating.82 This finding bolsters Kirsch’s claim that patients view experienced side effects to be directly tied to antidepressant efficacy.
Though patients often associate side effects with efficacy, many do not realize how dire some side effects may be. This ignorance may be due to the pharmaceutical industry’s overemphasizing their drugs’ advantages while shielding the public from the disadvantages.83
Common side effects of most antidepressants include “dizziness, gastrointestinal complaints, dry mouth, sweating, emotional flatness, insomnia, drowsiness, tiredness, decreased libido, and for male patients also problems with erection and ejaculation.”84 This list does not include other less well-known side effects. Some studies even suggest that antidepressants raise suicidality and self-harm rates when compared against control groups.85
Side effects are commonly noticed and reported by patients. These most commonly include “decreased libido, tiredness, feeling drowsy, insomnia, emotional flatness, sweating, a dry mouth, and intestinal complaints.”86 The presence and worry concerning these side effects often cause significant adjustments to patients’ daily lives.87
Despite significant side effects, doctors often diagnose depression and prescribe antidepressants inaccurately. Approximately 11% of diagnoses and subsequent antidepressant treatments are incorrect and do not meet “diagnostic criteria for depressive or anxiety disorder.”88 Using present census data89 and the WHO’s report on the number of adults currently taking antidepressants,90 the data would suggest that, by psychiatric diagnostic standards, at least 3.75 million American adults are presently taking unnecessary medication with significant and potentially severe side effects.
Antidepressants have become an easy out for those without proven biological problems; pop a pill and feel the negative emotions fly away. People have begun to believe they no longer have to live with sadness or fight with negative emotions, which were once considered meaningful to the human experience. Poignantly, “A biochemical understanding of mental ill health may be embraced because it relieves people of responsibility for their circumstances, but relieving people of responsibility can also result in a sense of hopelessness.”91
To many health professionals, “better” means less sadness despite the side effects. But why is the absence of sorrow better? This thought is entirely arbitrary to a belief that condenses man to biology alone and denies him a soul. Why should doctors try to make people feel happy through drugs alone if more hopelessness is the typical result?
This question leads to the central theological problem with psychiatric philosophy. The modern model or biochemical understanding of people’s inner-man struggles is oversimplified and incomplete. The spiritual fallacy of psychiatric claims is the denial of man’s soul. “A[t] the price of curing the few, biopsychiatrists will mislead the many. They do not act as their own theory ought to predict, as machines or mere organisms. They act like people made in the image of God and misdirected by sinfulness.”92
The Bible contends for both the physical and spiritual aspects of man. There are physical causes for depression, such as medication side effects, chronic illnesses, physical neglect, genetics, thyroid issues, and postpartum issues.93 There are also countless spiritual reasons why people experience depression based on their circumstances, choices, daily stresses, or spiritual deadness.
Every person is “morally insane with sin, living as if we were gods.”94 Telling a patient that their sadness is purely biological and can be healed with a pill is significantly easier than asking that same person to fight and battle sinful desires regardless of how they feel. Not all depression is a result of the individual’s sin, but all depression is at the very least an indirect result of original sin. In a branch of study that doubts the reality of the spiritual, this answer seems fallacious even if it is theologically accurate. After all, “It’s too unpleasant to say that we are sinners against the God and Father of Jesus Christ the only Redeemer. People want to say that we are essentially bodies, because then we can fix what ails us.”95
Christians believe in physical reality as well as spiritual reality. This concept was widely accepted among all people, with few exceptions until quite recently. God exists. He created man in His image. Therefore, man must find his ultimate purpose and happiness in God.
Because God exists as the foundation for all reality, the existence of truth—absolute objective truth—is unquestionable and must be found in the person of God. A purely biological view of humanity is a purely materialistic view of the universe. This philosophy of biological reductionism has no home for a spiritual God that underlies all physical reality. Much less does psychiatric philosophy have any tolerance for a spiritual Being who could “sanctify” the immaterial souls of people.
Antidepressants within Biblical Sanctification
Understanding Biblical Sanctification
What is Biblical sanctification? Biblical sanctification is the process God uses to grow His children to look more like Him. This process is full of mountains and valleys, growth and stagnation, but sanctification has an upward trajectory over the believer’s life. In justification, the believer is declared righteous before God. In sanctification, God patiently molds the believer to his glorified status.
Sanctification implies change. God is intimately involved in the development of His children. Those God does not sanctify He never justified. This growth is primarily in the soul of man, but its fruit is available for all to see. In the soul, sin is fought, the will is disciplined, and emotions are satisfied. Through sanctification, the Christian fights evil and becomes genuinely “better.” And in this sanctification, God often uses emotions the culture considers harmful to grow believers closer to Him.
The Holy Spirit is the agent of sanctifying change and the cure for man’s soul problems. Apart from the Holy Spirit, there is no cure. Psychiatry and even psychotherapy may claim their methods as foolproof cures for depression. A pill or a doctor’s good word may satisfy their client’s longing for a moment, but only the Living Bread and Water can satiate man’s hunger and thirst forever.
Though beyond the breadth of this study, one tool the Holy Spirit uses to sanctify God’s children is the community of Christ. The church is an integral piece of the Christian’s sanctification. On the topic of depression, the church member has a responsibility to seek aid from his brothers and sisters. He is called to rest, to lay his burdens on his brothers’ and sisters’ backs as they “weep with those who weep.”
Prioritizing Biblical Authority
Another tool the Holy Spirit uses is His Word, the Bible. The Bible has the power to bring lasting change to people’s lives. By its words and teachings, it molds the soul of man: the bed of intellect, will, and emotion. It claims the power to destroy sin and encourage the hopeless. It is God’s Word, and it is alive.
There is a problem in modern evangelical Christianity. Hindson states, “Today there is a dichotomy in the church on two levels. First, we have a church that professes to believe the Bible is inerrant, but it is not sufficient for matters of faith and life…. Second, we have a church that professes to believe in an inerrant Bible that is sufficient for justification, but not for sanctification.”96
Many in modern Christendom have become overly fascinated with the claims of science. In their awe, some have attributed to science the authority Christians have attributed to the Bible for thousands of years. After two millennia, the Bible is no longer sufficient for people’s inner-man struggles. Anger, anxiety, depression, a pill can cure all these “negative” emotions. So why not? As science reports back on usage, they realize too quickly that antidepressants are not the simple cure promised by the psychiatric community.
Christians must once again raise the banner of Biblical authority and sufficiency if they long to bring help to the helpless. For too long, Christians have abdicated their responsibilities to the culturally mandated field of psychiatry, a science that denies the existence of the soul, the very factory of depression. While psychiatric science is constantly rewriting itself, believers must remember that they hold God’s Word, an unchangeable bulwark. As Powlison states, “The Bible is an anvil that has worn out a thousand hammers.”97
Perhaps, one of the reasons Christians are so confused about this issue is because many have unknowingly accepted the cultural lie that emotions such as anxiety, grief, anger, or long periods of sadness such as depression are entirely negative. Some act as if everyone should avoid these emotions at all costs. However, emotional struggles, such as depression, are painful and unpleasant but can also be meaningful, enlightening, and essential to Christian growth.
This tendency to flee from these more complex emotions is natural. A culture that overvalues the “happiness” found in materialism, self-love, and lustful pleasures exasperates this trend. Moreover, if someone is feeling sad, there is a pill for that. No wonder even Christians feel the need to “put on a smile” and hide their darker emotions from those around them.
But depression is no sin, nor is there any reason for guilt. True, at times, depression may be a temptation to sin, but just like every other temptation, it is also an opportunity to do right and glorify God. And often, depression is an important reminder that the Christian may have heart issues deep within his soul. As Fitzpatrick writes,
So, is there any place for antidepressants in sanctification? Should Biblical counselors ever recommend antidepressants? There is nothing in Scripture banning the use of drugs in helping with depression. However, based on issues previously stated (placebo effect, side effects, faulty science and philosophy, diagnostic practices, etc.), the Biblical counselor needs discernment and possibly some hesitation before recommending a counselee to a physician in hopes of an antidepressant prescription.
Most Biblical counselors are not physical doctors and should be very careful not to give physical counsel outside of the scope of their expertise. A Biblical counselor should not try to take a counselee off their antidepressant drugs. Instead, they should focus on Biblical counsel. If the counselee desires to stop the medication and the counselor has seen significant growth to warrant this move, the counselor should refer the counselee to their physician.
Sometimes depression is significantly physical, as in medication side effects, chronic illnesses, thyroid issues, and postpartum issues.99 When a clear biological issue substantially affects the counselee’s mood, counsel with a physician may be necessary.
At other times, the counselee may be so overwhelmed that the counselor worries for their safety. While depression may be a foundationally spiritual issue, the spirit affects the body. Perhaps a prescription can restrain some of the side effects so that the counselee may listen to the counselor with a clearer mind.
When the counselor is counseling someone prescribed antidepressants, the counselor needs to express that ultimate hope should be found in the counselee’s relationship with Christ, not medication. Counselees must understand they still have a choice to do right regardless of the pain of their depression. Unless mentally incapacitated, physical sources for depression do not remove someone’s spiritual responsibility. Sanctification is not found in a drug but in the life-changing power of the Holy Spirit and His movement through the Bible and the church in the believer’s life.
Antidepressants are significantly less effective than posited by pharmaceutical studies, never mind other issues such as side effects that can severely affect a person’s mode of life. While not useless, antidepressants are overprescribed underperformers. They are not cures for depression, practically or philosophically: practically, because research on their efficacy is mixed at best and fallacious at worst, philosophically, because depression is not usually a biological disease but a symptom of the hurting soul.
False claims and spotty science mar the history of psychiatry, but where are people to turn when the church has abdicated its responsibility of soul care? The Bible answers the inner-problems people face and the emotions with which all struggle, including depression. Churches and Christians must begin to ask, “Do we truly believe that the Bible is our final authority and that it is sufficient for our inner struggles? Or do we merely say we believe in these principles and live as if we do not?” If Christians do not reestablish Biblical authority, helpless souls will continue to rely on powerless methods and find themselves no better off. As Vilhelmsson writes, “Maybe we ought to ask ourselves if it is really the responsibility of the doctor and the health care system to handle everyday problems or whether people turn to these institutions because they have nowhere to go.”100