BCC Staff Note: You’re reading Part 3 of a three-part BCC Grace & Truth blog mini-series on “Biblical Counseling and Medication.” You can read Part 1 by Brad Hambrick at 6 Steps to Wise Decision-Making About Psychotropic Medications. And you can read Part 2 by Mike Emlet at Listening to Prozac… and to the Scriptures.
My Dual Roles…
As a family physician, I am often asked about taking medicine for depression and other disorders. Also, as a biblical counselor, I have been involved in counseling people who struggle with depression and worry for the past 25 years. I counsel them every Monday night, and again I am answering the same kinds of questions about medication.
More than anything else, I want to do both roles (family physician and biblical counselor) well and fairly. When it comes to the question of taking medicine for depression, I want to make an accurate diagnosis and provide the best care possible in a kind and caring way. That sounds simple enough but sometimes it is difficult to meet everyone’s expectations.
When patients come to the office and believe they are depressed, they are almost always expecting me to prescribe medication. They have been educated over the past three decades by governmental agencies and pharmaceutical companies to believe that all sadness is depression.[i] They have also learned depression is a disease that should be treated with medication.
I also know that there are many good people who have differing opinions about this subject, and that sometimes there are disagreements that can be a little contentious. In part, the disagreements exist because we lack scientific factual evidence to confirm the diagnosis of depression. Many believe that depression is over-diagnosed and over-treated for the same reason. I think that all of us in medicine and biblical counseling can do better on both counts. There are other problems in medicine that have suffered with the same over-diagnosis and over-treatment that have changed when we decided to apply facts to the problem.
One such example is the over-diagnosis and over-treatment of gastro-esophageal reflux disease or GERD in healthy infants.[ii] Over the past decade it has become well understood that when the diagnosis was made without testing, it was being over-applied to otherwise healthy infants. The lack of objective testing led to over-diagnosis and treatment with medicines that have significant side effects and which did not help the child.
Recently a research project examined why this diagnosis was being made so frequently and why so many children were taking medication. Researchers found that if otherwise healthy thriving children who were crying and irritable after spiting up were taken to see a doctor, what the doctor said made all the difference. If the doctor mentioned the possibility of a diagnosis of GERD to the parents and then offered to give them medicine, the parents most likely would agree to treat the child.
If the doctor did not use the term GERD, but only described the normal spitting that 80% of children do, that made the parents less likely to want to treat. And, if the doctor informed the parents that the acid-reducing medicine had been studied and shown ineffective in treating the irritable crying, then the parents were least likely to want a prescription.
The key to over-treatment was how the parent was educated by the physician and others. The same holds true for using antibiotics needlessly for viral infections. And, it is also true for depression.
The 2 Questions We Should Be Asking
When most patients present to a physician for treatment of depression, they are not exactly looking for a diagnosis. Most will have seen the commercials on television describing depression and delivering the message that taking the advertised medication will help their problem. They come already “educated” and they expect a prescription.
There is no objective testing to do. There are no blood tests, x-rays, or specific findings on physical exam that can verify the diagnosis. The only thing we have to go on is the history and the criteria found in the Diagnostic and Statistical Manual of Mental Disorders.[iii] Unfortunately the criteria are only used about half the time by practitioners when making the diagnosis. And, without any laboratory testing, the criteria cannot be confirmed to be valid.
The patient tells the doctor about their sadness and depression. If things go well, the doctor checks off the criteria in his or her head, and when enough are met, the diagnosis is made. The physician agrees with the patient. Generally a prescription will follow. And, just like the children in the study, antidepressants have become the number one drug prescribed for people aged 18-44. Their use increased 400% from 2005 to 2008.[iv]
There is good reason to believe that the diagnosis of depression is being applied to people who are simply normally sad over loss.[v] The questions we should be asking are, “How can we make a better diagnosis?” And, “How can we do a better job of helping?”
Time and trusting patients have allowed me to develop an approach to helping when sadness and depression are their problems. The following is what I do to help the patient work through the process. Please keep in mind that I work in a secular office with a good employer who has reasonable expectations of my interactions with patients. I am also limiting the discussion to depression as it is one of the more common problems treated.
In the Office
The first order of business is a complete history of the patient’s problem, a complete physical, and then appropriate blood work. I am looking to find emotions and actions that will meet the criteria set for the diagnosis of depression. I am also looking for any indication that they may have another medical diagnosis that might contribute to a sad or anxious mood. The patient’s medicine list is very important as we know that there are many medications that can affect mood.
The most important part of the history has to do with the onset of their problem. I need to know what happened when their sadness started. Current research has told us that nearly 90%[vi]of those labeled as depression today are struggling with normal sadness over loss.[vii] An event has happened in their life that has taken away something that they value most in life.
Those who cannot tell me of any event or loss make up the remaining 10% that we have labeled in past years as having disordered sadness or sadness with no apparent cause. Prior to 1980, physicians limited the diagnosis of depression to those with disordered sadness who could not tell us why they were sad.
With that difference in mind, I will tell the patient the following things as we work towards their choice of care. Keep in mind that most of all of the patients who come to see me because of depression expect to receive a prescription.
1. The first thing I do is acknowledge that the patient is struggling with sadness and that they meet the current diagnostic criteria for depression. They need to know that I believe that they have real problems. I want them to know that I want to help them as much as I can.
2. I discuss the options for care. I point out that the current research tells us that 80% or more of people who struggle with sadness and depression will benefit just as much from talking with someone skilled in helping as they would if they took medication. And, that the long term benefits appear to be better.[viii] I tell them that they have a choice to make. They can either talk with a counselor about their struggle, they can take a medication, or they can do both.
I also tell them that if they choose to talk with someone that they can pick from one of three options. They can see a psychiatrist, a psychologist/social worker, or they can talk to a pastoral counselor.[ix] The latter category opens the door for me to direct them to someone skilled in sharing the solutions found in Scripture if they choose that option.
3. I discuss the benefits and side effects of the medication at length. No patient should take any medicine prescribed to them without a good understanding of what problems might come from taking it. I tell them that for very severely depressed patients that the medicine does seem to help. I also tell them that for nearly 90% of those who take them that our current medications have not proven to be as helpful as we had hoped.[x] There are also significant side effects that go beyond the scope of this article and every patient should discuss these with their physician carefully. We discuss the changes in personality that are seen with the current medicines used for depression.
4. For those who have no identifiable loss, I still emphasize the importance of counseling.
5. Then I let them choose. I have found that over the years most patients want a medication. That has become our societal norm. An encouraging trend I have seen is that most patients who are coming now for sadness and depression will ask for medicine, but will also take the advice to seek counseling. And, that gives them a greater opportunity to find help.
On Monday Night
A large percentage of those who come for counseling at our biblical counseling center are taking medicine before they come. They come because the medicine has not solved their problems. They come sometimes as a referral from a physician or a friend.
It is uncommon for individuals who come for counseling who are not taking medicine to ask me if they should be taking it. The more common question that comes is from those who are already taking it. They want to know if I think it is right or wrong to take the medicine.
My response to them is to share that taking medication is neither right nor wrong. In fact, it’s the wrong question. The questions we should be asking are: 1) Whether or not the medicine works and, 2) If the benefit is worth the side effects.
I tell them that taking medication for depression is a Romans 14 issue. From that chapter the church has derived the doctrine of Christian Liberty. If the Bible does not say exactly what we ought to do in a certain situation, then we as believers have the privilege to choose what we wish to do in the light of the rest of the Bible. Nothing in the Bible talks specifically about the right or wrongness of taking medicine for depression, and it becomes a matter of our choosing. Whether we choose to take medication or not for depression, it should not become a matter over which we judge others. And, that must be true in both directions. As in Paul’s day, those who did not eat were not to judge those who did and vice versa.
Sometimes counselees will want to know the benefits and risks of taking medication. I work through the same research that I do with patients in the office. That gives them a good understanding of the benefits, limits, and side effects of the medicine they are taking.
The goal of the office process and in counseling is to make a better diagnosis. This requires careful listening in order to identify the majority of those who struggle with normal sadness and those with disordered sadness. The most important thing I can do then is educate them as to what their best options are for care.
This allows the patient and the counselee the opportunity to make an informed choice about taking medicine for depression. It gives them the opportunity to make that choice in the framework of our liberty as Christians. At the end of the day as a physician and biblical counselor, I am glad to be able to help.
Join the Conversation (Added by the BCC Staff)
Having read all three blog posts in this series, how would you compare and contrast the perspectives shared?
What is your perspective on biblical counseling and medication?
[ii]“Influence of ‘’GERD’ Label on Parents’ Decision to Medicate Infants,” DOI: 10.1542/peds.2012-3070 Pediatrics 2013;131;839; originally published online April 1, 2013; Laura D. Scherer, Brian J. Zikmund-Fisher, Angela Fagerlin and Beth A. Tarini.
[vi]Jay Fournier, Robert DeRubeis, Steven Hollon et al. “Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-Analysis,” Journal of the American Medical Association, 303: 1 (January 6, 2010), 51. “True drug effects (an advantage of antidepressant medication over placebo) were non-existent to negligible among depressed patients with mild, moderate, and even severe baseline symptoms.