"More problems than it was helping”: Behind the growing distrust of antidepressants

In 2017, Julie moved to Massachusetts to start a new job in biotech. She was maintaining her relationship with her partner long distance, and starting a new position in an unknown city alone had her distressed. Her psychologist and doctor recommended she start taking the antidepressant Prozac (fluoxetine) to feel better, and it helped her function — for a while.

Then years went by, and she started to develop other symptoms. Her insomnia got worse. She felt oddly detached from herself and she started to have thoughts about suicide that she had not had before. During this time, she was processing traumatic experiences from her childhood in therapy, but she felt like these symptoms were being exacerbated by Prozac. So in 2022, Julie started tapering off of her medication after talking with her primary care doctor.

“I just continued taking it, sort of without questioning,” Julie, who is using a pseudonym to protect her privacy, told Salon in a phone interview. “I came to believe that Prozac was causing more problems than it was helping.”

Antidepressants like Prozac were a major breakthrough in psychiatry when they were first marketed in the 1980s. However, their use has become so widespread in the U.S. that some argue they are now being overprescribed. In fact, an entire internet subculture has developed to help people get off of their antidepressants, which doctors warn can be dangerous if not performed under the medical supervision of a health care provider. 

In an executive order issued in February, President Donald Trump said the administration would “assess the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors,” referring to SSRIs, a common class of antidepressants and other psychiatric medications. During his testimony at the Senate Finance Committee, secretary of the Department of Health and Human Services Robert F. Kennedy Jr. also said that antidepressants were harder to get off than heroin.

Antidepressants can be life-saving and life-enhancing for many people, but for most people with mild or moderate forms of depression they are not intended for long-term use. The drugs can also carry side effects that can significantly impact a person’s quality of life, including weight gain, sexual dysfunction and emotional blunting, in which people feel fewer positive emotions along with negative ones. While Kennedy is wrong — antidepressants are not harder to stop using than heroin — the withdrawal process can come with its own side effects as well, which some argue is an underrecognized problem.

“These are very individualized things,” said Dr. Mark Olfson, a psychiatrist at Columbia University. “There is no one-size-fits-all in terms of how people make trade offs between the burdens of staying on the medication versus the protection the medication offers some individuals.”

The most commonly used antidepressants today are SSRIs like Prozac, which came on the market in 1988. In the decades that followed, the prevalence of SSRI prescriptions continued to increase year over year to a climax in the pandemic when the proportion of the U.S. population taking antidepressants approached 25%. This more than tripled the proportion of people on them in 1990.

Depression has also increased over the years, or at least has been detected in more people. Yet the proportion of the population with depression remains lower than the proportion on antidepressants, in part because these medications are also commonly prescribed for other conditions like obsessive-compulsive disorder, eating disorders, insomnia and anxiety — which has also increased in the U.S. in recent decades.

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Still, some believe they are inappropriately prescribed for too long, or in cases when lifestyle changes or psychotherapy should be tried first. However, many people with depression and severe anxiety who could benefit with antidepressants are also not getting the help they need, Olfson said.

“I do think there was and maybe still is overprescription,” he told Salon in a phone interview. “But at the same time we have people overtreated, we also have people who are untreated.”

Although antidepressant use is still on the rise, a study Olfson co-authored last month found that, for the first time since these drugs were introduced, the use of psychotherapy increased at a higher rate than medication alone. This may in part be due to the increased availability of telehealth counseling, he explained.

“It's still the case that most people with depression or anxiety who receive treatment receive antidepressants, but in the last few years, a rising proportion of them are receiving psychotherapy and the growth of psychotherapy has occurred more quickly than the growth of antidepressants,” Olfson said. “This change is coming after years and years of medications just sort of dominating mental health care in America.”

However, psychotherapy remains steeped in stigma and inaccessible to many. This may be one reason that antidepressants are prescribed when other strategies could work as well. Sometimes a person’s only point of contact with a medical professional who could help them with depression is their family doctor, who could refer them to a psychologist. But if they are not available or too expensive, patients are left with few options other than antidepressants, explained Dr. Awais Aftab, a psychiatrist at Case Western Reserve University, who said we often end up using antidepressants “as a matter of structural convenience."

“However, if you look at the practice guidelines, they recommend that for mild to moderate depression, it is better to start with psychotherapy and lifestyle change and reserve antidepressants for cases of mild to moderate depression that are not getting better or those of more severe intensity,” Aftab told Salon in a phone interview.

Julie struggled to find an affordable psychiatrist in her area that could help guide her through the process of getting on antidepressants back in 2017. Her primary care doctor ended up overseeing her prescription, but once she got on Prozac, they didn’t really discuss it anymore, she said.

Aftab said this can happen often: “They just put people on antidepressants and then they kind of forget about it and it just keeps getting refilled,” he said. Then, the discussion about whether the medication is working or if they need to stay on it "doesn't really happen,” he explained.

However, the problem with staying on antidepressants longer than necessary is that withdrawal symptoms can be more difficult the longer you stay on them. If someone is stopping antidepressants, it's recommended to wean off them slowly and under medical supervision because doing so too quickly and without the right dosage can be dangerous. It can lead to side effects such as a symptom called "brain zap" in which patients feel sudden shocks in their head.

Depending on a range of factors including the dosage and medication, it can take months or more. Julie did it in eight weeks, but she experienced symptoms that were worse than the original depression she felt, she said.

“My biggest symptom after that was extreme anhedonia, like a feeling of not being myself or getting pleasure from anything — almost not feeling human,” she said. “Along with extreme physical fatigue, both of those symptoms lasted for about two years.”

Sometimes the withdrawal from antidepressants can be mistaken for the return of the original depression it was intended to treat. This could lead some people to go back on medication, if the feeling is so uncomfortable that being on the medication ends up providing relief, Aftab said.

Overall, there is relatively limited research exploring the right protocol to get off of antidepressants and how to avoid the symptoms of withdrawal, Aftab said. There is even still much debate about what causes depression in the first place. In 1967, an English psychiatrist named Alec Coppen proposed the “serotonin theory,” suggesting a chemical imbalance of serotonin in the brain caused depression.

In response, the pharmaceutical industry developed Prozac, the first SSRI. However, in the decades that followed, some questions were raised about the trials used to demonstrate the effectiveness of SSRIs. Around the same time, researchers started to question the serotonin theory that had been publicized as a potential cause of depression.

Joanna Moncrieff, a professor of critical and social psychiatry at University College London, co-authored a review in Nature in 2022 that concluded there was “no consistent evidence of there being an association between serotonin and depression.” 

“We can’t conclude that depression is related to serotonin abnormality,” Moncrieff told Salon in a phone interview. “The evidence for the serotonin theory of depression was weak and inconsistent but the general public thought it wasn't just a theory: They thought it was an established scientific fact.”

Moncrieff’s paper received significant backlash, with five responses published in the journal along with a comment authored by 35 academics that challenged Moncreiff’s findings.

It’s likely that the cause of depression is far more complex than something operating on a single neurotransmitter like serotonin, said Philip Cowen, a professor of psychopharmacology at the University of Oxford and one of the co-authors on the comment.

Nevertheless, that doesn't mean these drugs don't help people. For one, it's common for medications to not target the direct cause of illness. Instead, many are designed to alleviate symptoms and suffering, Cowen explained. For example, asthma inhalers activate receptors, which relax the airways to help facilitate breathing. This helps with asthma symptoms but does not treat the direct cause of asthma, which is ultimately an allergic reaction. A similar thing may be happening with antidepressants, Cowen said.

“[The serotonin theory] is a simplistic view and it can't be right,” Cowen told Salon in a phone interview. “Taking SSRIs might make you feel better for various psychological reasons, but it doesn't necessarily mean it's working on a fundamental problem with serotonin.”

Although these medicines are still not fully understood, the fact remains that antidepressants do help many people feel better. Yet the back and forth within the medical community about the efficacy of antidepressants and the cause of depression might be why some have grown to mistrust them. Other false claims in the media and some scientific papers have stated that antidepressants can be addictive like alcohol.

Add on misleading criticisms from the White House, and more people are likely to get off of them, said Rifaat El-Mallakh, a psychiatrist who leads the Mood Disorders Research Program at the University of Louisville Depression Center. 

“When you have your leaders saying things like, 'it's harder to get off an antidepressant than it is to get off heroin,' you say, ‘Oh my god, I better get off now before I'm stuck on this forever,’” El-Mallakh told Salon in a phone interview.

As distrust grows and it remains challenging for many people to access psychotherapy or medical treatment, many are seeking advice online. In fact, there is an entire subculture online where people talk about getting off of their psychiatric medications. 

While Julie did talk with her primary care doctor about getting off her medication, she felt there were more resources on the internet, she said. As she explained: “Most of the support I got through that process was just through online forums.”

Despite the difficulty of the withdrawal process, Julie has been tempted to go back on them again during challenging parts of her life. If she is ever in a place where she feels like her own safety is threatened by her mental health, she would consider it, she said. At the same time, she questions whether she actually needed them in the first place.

“I wish we had a different culture in the medical care community around recommending antidepressants,” she said. “If they were treated more as a last resort, then maybe I would have made a different choice.”

Nevertheless, Julie feels more stable these days and developed strategies in the process of the antidepressant withdrawal that help her move through challenging moments, she said. Some of her symptoms, like problems with her libido, have not fully recovered. But she has started exercising again and feels like her body is more responsive to lifestyle changes she implements.

“I think getting better is now a bit more under my control,” she said. “So there is potential for things to keep improving.”