Cover Story

Job on Prozac: The pharmaceutical option

In the biblical story, God tests his faithful servant Job to see whether Job will stay devoted to God even if God takes everything away from him. Now you don’t lose your family, health and possessions, as Job did, without falling into a terrible funk. It’s possible, then, to understand Job’s story as being about remaining true to God through a devastating depression. Suppose that Job had had a prescription for Prozac to help lessen his pain. Would it have been cheating to take a couple of tablets a day while God was tossing all manner of pestilence at him?

I suspect that if Job were around today, he would be strongly advised to get himself to a mental health clinic for a prescription. After all, the most important thing is to keep following the Lord. If depression prompts you to turn off the road, and Prozac keeps you on it, then don’t think twice—take your pill.

In his Doctrine of Virtue, Immanuel Kant argues that we have an indirect duty to make ourselves happy, because when we are miserable we are less likely to fulfill our moral duties. Similarly, it could be argued that if I know that I lose faith in God when I am blue, then I have an indirect religious obligation to take medications that will protect me from depression.

In his recent book Finding God in Prozac or Finding Prozac in God: Preserving a Christian View of the Person Amidst a Biopsychological Revolution, Charles Biovin contends that Christians should not hesitate to use the new brands of antidepressants such as Prozac and other selective serotonin reuptake inhibitors—commonly referred to as SSRIs—as spiritual lifesavers. Biovin argues that even a casual study of the Old Testament reveals that the fathers of our faith might today be classified as reductionists who believed that the soul and body are one. The Hebrew prophets would have been quick to agree that melancholy is a physical malady.

While I am not as sanguine as Biovin about either the efficacy of SSRIs or the claims that they are physically innocuous, many people have found a balm in this new class of medications. A friend swears that Prozac saved her life. Other people attest that if it were not for antidepressants they might have died to the idea of a personal God. In a Christianity Today article, a woman states that while she was depressed she went to church only because she feared the frowns of other parishioners. However, after a few weeks on Prozac her motivation changed. “Now I go because I truly desire to be in God’s presence. So, in the sense that I no longer feel the need to fake my spirituality Prozac has replaced religion for me—though it has not replaced true spirituality.”

As Biovin observes, “It is perhaps this aspect of the Prozac revolution for persons of faith that is the most provocative. Not that it can enhance emotional or psychological well-being where prayer did not; rather, that it reveals to us more than ever just how inextricably interwoven the biochemistry of the brain is to who we are and how we relate to each other. Whether we like it or not, Prozac and its successors have become enmeshed in the fabric of day-to-day American life and cannot help but challenge persons of faith to reconsider the nature of spiritual well-being and renewal.”

Things like Prozac, Alzheimer’s disease and taking a few stiff drinks all remind us that biochemical changes in the body can radically affect the way we think and feel. Nevertheless, these reminders do not compel us to believe that our feelings are simply the echoes of chemical perturbations. The fact that physical interventions can alter our experience in systematic and predictable ways does not imply that all our experiences are reducible to physical causes. But Biovin is correct that perfervid faith in pharmaceuticals challenges traditional ideas about psycho-spirituality, perhaps in ways that should give us pause.

For all the fanfare about radical breakthroughs in neuroscience, we have no scientific reason to believe that our emotional lives can now be understood in purely physical terms. The relative success of the use of SSRIs in treating depression suggests that there may be some relation between neurotransmitters and melancholy; however, that is about as far as our current knowledge goes. In his comprehensive atlas of depression, The Noonday Demon, Andrew Solomon observes: “It is comforting to think that we know the relationship between neurotransmitters and mood, but we don’t. It appears to be an indirect mechanism. People with lots of neurotransmitters bumping around in their heads are not happier than people with few neurotransmitters. Depressed people do not in general have low neurotransmitter levels in the first place. Putting extra serotonin in the brain does no immediate good at all.”

More than a few who suffer from depression do not respond to medication but do respond to intensive psychotherapy. Serotonin aside, many people marvel over brain-imaging studies as though the MRI were a font of revelation. However, the fact that parts of the brain light up or fail to light up in depressed people is hardly proof that biochemical processes alone are responsible for depression. There are neurological correlates for every form of mental activity, and, as Biovin himself acknowledges, just because imaging studies show that religious experiences are correlated with activity in a particular part of the brain, it does not follow that that activity is the cause of religious experience. Whether or not depression is best understood in biochemical terms remains an open scientific question.

The Scottish philosopher David Hume argued that when we cannot decide the truth or falsity of an idea on empirical grounds alone we should consider its moral effects. Following Hume, it might be useful to ask, “What are the spiritual effects of believing that psychological problems are fundamentally biochemical in nature?” Many people writing on the issue of faith and pharmaceuticals are legitimately concerned that some people try to pray their way out of psychological squeezes that could be treated effectively by medication. While I acknowledge this danger, I am concerned about a different complex of problems, such as our tendency to medicalize all experience.

Every year more and more students approach me at the end of the semester to confess that they have one or another psychiatric problem that is beyond their control, and to insist that because they are clinically depressed, bipolar or have attention deficit disorder they must be given extra weeks to hand in their work. Having walked under the black sun myself, I almost always agree to an extension. Still, I often want to inform these students that many great writers have kept writing through soul-chilling bouts of melancholy. My charges, convinced that they are suffering from a chemical imbalance, would find such a homily anachronistic.

These currents of the classroom have also entered the pews. The Prozac literature has it that the loss of faith resulting from feelings of hopelessness is a medical problem. But if religious numbness is the result of nothing but molecules in motion, then what about feelings like envy, lust and rage? Christianity claims jurisdiction over the heart. Indeed, Jesus admonishes us that to lust after someone in our hearts is as a bad as acting on that lust (Matt. 5:28). And yet, if depression can be chalked off to chemistry, then why not concupiscence? No doubt many Christians think that if Jesus only had known what we know about the brain, he would not have uttered such hard and hyperbolic sayings.

Make no mistake about it, the Prozac revolution has implications for our understanding of sin—implications that people may or may not find disturbing. Many who believe that Jesus washed away our sins will not be troubled by the fact that sin is quietly being ushered out the same back door through which judgment and the Evil One departed. Recently I attended a Good Friday service that made no mention of sin. Afterwards, I screwed up my courage to press the pastor about omitting sin from his sermon. He explained that talk of sin only makes people feel bad about themselves. Speechless at this triumph of the therapeutic, I walked off musing about Kierkegaard’s claim that what we really need a revelation to understand is sin, not the idea of the forgiveness of sin. Indeed, faith may require us to believe we are responsible for states of mind that doctors assure us are not sins at all, merely symptoms of a medical condition.

Pharmaceutical fundamentalism also invites misconceptions about moods and feelings. In the argument for the spiritual efficacy of drugs, much is made of feeling or failing to feel God’s presence. But what exactly is the relationship between feeling God’s presence and faith? The question of faith is answered not at the level of feelings but in regard to the way we relate to our feelings. Whatever else faith is, it involves trusting that God is there even when God seems absent. When Jesus seems a cold abstraction, faith requires us to consider the possibility that we ourselves have locked the door that Jesus seemingly refuses to open. The old orthodoxy had it that when we can’t relate to God we ought to search ourselves and reflect on whether perhaps we have made a god of something else.

If the only way that we can feel the breath of prayer is by leaving our office jobs and living on farms, then we probably should pack our bags. If the only way we can remain alive to God is by smoking grass or taking Prozac, then it might be best to bow our heads and use whatever drugs we need to awaken spiritually. After all, many religions throughout the world have relied very heavily upon the use of drugs. But it is one thing humbly to admit that we need something to make us feel well enough to pray, and another to conclude that when we cannot relate to God it is always only because we are low on neurotransmitters.

For all the stress that the God-and-Prozac evangelists put on feeling God’s presence, they regard other moods and affective states such as anxiety and depression as of little or no spiritual significance. In an 1843 journal entry the melancholic Kierkegaard noted that the worst fate that can befall a person is to regard “the substance of his feelings as drivel.” And yet presenting the emotions as drivel is just what the medical model does. The biochemical catechism treats depression and anxiety as pathogens that obscure our spiritual vision and make us strangers to ourselves.

In contrast, Kierkegaard and others maintain that the emotions have a cognitive component. For example, Kierkegaard believes it is through the experience of anxiety that we come to understand we are free. In the coda to his Concept of Anxiety he describes anxiety as a teacher imparting the fundamental theological truth that we can do nothing without God. In the television ads that drug companies run at half-time between beer commercials the message is always that our malaise, social anxiety or nervousness is a meaningless internal miasma that can be dispersed by a few pills—pills that will return us to our true alacritous selves. There is no need to try to understand our feelings.

In addition to peddling misconceptions of sin and the emotions, the better-living-through-chemistry movement invites a new form of idolatry. The pre-Prozac counsel for combating melancholy was that we should reach out for the hands of our neighbors. However, we Americans are so obsessed with autonomy, so nervous about feeling emotionally needy, that we much prefer seeking solace in a bottle to calling a friend and asking for help. Many people on psychotropic drugs actually feel as though they have a friend in their medicine cabinet.

A couple of years ago I argued in these pages that those of us on prescription psychotropic medications ought not to be judgmental about the uninsured people who try to assuage their depression with illicit drugs. One man who took umbrage at my argument nevertheless proclaimed, “With God and Prozac I will make it!” Lauren Slater, who recounts her problems with Prozac in Prozac Diary (1999), still felt as though she found a slice of salvation in serotonin. She writes, “Falling in love is a state of surrender, not necessarily pleasant. Like a depressed person, you let yourself go . . . you just say yes. Yes. I fell in love one day, only it was not with a person; it was with my pill.”

Reliance on pills spares us from the messy business of having to think about and make sense of our experience. Prescriptions can spare us all the indignities of needing others. For many, Prozac and its chemical cousins provide a feeling of autonomy and choice—two words that are veritable god-terms to Americans.

It is a well-known fact that people in the U.S. use more psychotropic medications than the rest of the world combined. While I am not against the use of drugs to treat depression, I do think that faith in chemistry has its spiritual temptations. The first time Prozac lost its magic for her, Slater wrote: “Prozac had betrayed me . . . but not before its belief system had leached to the very root of me, the belief that, when all is said and done, we are beyond the grace of stories, that only chemicals can cause hurt, and thus only chemicals can cure.” And that conviction is spreading as though it were the Good News itself.