Like every psychiatrist, I have patients for whom antidepressants are transformative, even lifesaving. But I also see a messier, less advertised side of these medications. There are patients with sexual side effects that they hadn’t known could be caused by their antidepressants because previous doctors never warned them. I’ve had patients experience manic episodes or suicidal thoughts with specific antidepressants, and patients who no longer need to take the drugs, but suffer severe withdrawal symptoms when they try to taper off.
The medical community has reacted with alarm to Health Secretary Robert F. Kennedy’s claim that his family members have had a harder time getting off antidepressants than heroin. The American Psychiatric Association and five other psychiatric organizations recently declared that likening antidepressants to Schedule I drugs like heroin was “misleading” and emphasized that antidepressants are “safe and effective.”
But some patients heard Mr. Kennedy’s comments and felt that someone in a position of power was finally speaking for them. On online forums dedicated to helping people withdraw from antidepressants, such as Surviving Antidepressants, patients describe coming “undone” and going through “pure hell” in efforts to get off their medication.
They see in Mr. Kennedy someone who is alert to the seriousness of their problems, after years of neglect by the medical community, and it doesn’t matter to them that their experiences may be relatively rare or that Mr. Kennedy’s health movement, which disregards science and embraces anti-vaccine ideology, is unlikely to serve patients’ best interests.
Selective serotonin reuptake inhibitors, or S.S.R.I.s (the most commonly prescribed form of antidepressant) were originally studied for short-term use and were approved based on trials that lasted only a few months. But people quickly began taking the drugs for extended periods. Now patients are likely to stay on antidepressants for years, even decades. Of those who try to quit, conservative estimates suggest about one in six experiences antidepressant withdrawal, with around one in 35 having more severe symptoms. Protracted and disabling withdrawal is estimated to be far less common than that. Still, in a country where more than 30 million people take antidepressants, even relatively rare complications can affect thousands of people.
This is why it’s a travesty that nearly four decades after the approval of Prozac, there’s not a single high-quality randomized controlled trial that can guide clinicians in safely tapering patients off antidepressants. The lack of research also means that official U.S. guidelines for it are sparse. It’s no surprise that patients have flocked to online communities to figure out strategies on their own, sometimes cutting pills into increasingly smaller fractions to gradually lower their dose over months and years.
For many patients, it’s clearly worth it to start on antidepressants. There’s strong evidence that antidepressants are more effective than placebo, especially for short-term use. But, as for most medications, the effectiveness of antidepressants varies from person to person. Nearly a quarter to a third of patients find their depression remarkably improved or even resolved after starting medication, but a similar proportion experience no real benefit even after trying multiple kinds of antidepressants.
Given the routine long-term use of antidepressants, we need more research into whether a medication’s effects wear off over time, or if some patients experience more harm from prolonged use than others. But pharmaceutical companies are unlikely to do this research: They have no regulatory obligation to study these things, such studies are expensive to conduct and unfavorable findings can hurt a drug’s reputation. Federal funding, meanwhile, has prioritized basic research into causes of mental illness or drug development versus the kinds of questions that come up in medical practice like how to alleviate sexual side effects of medications.
Patients who come off antidepressants tend to be more likely to experience a relapse in symptoms of depression than patients who keep using them. But is that because their underlying depression is returning, or because they are in withdrawal? It can be hard to know. One of the best studies found that 39 percent of people who stayed on their antidepressants experienced worsening depression over a year compared to 56 percent of those who went off an antidepressant.
For many people, a 17 percentage point difference in depression risk is worth staying on a drug. For others, it may not be, especially if they experience significant side effects from antidepressants, like inability to orgasm, emotional blunting and weight gain. On the other hand, many of my patients with longstanding depression and anxiety problems report feeling more mentally resilient and better able to handle stress while on antidepressants. In those cases, I’m happy for them to keep using the medication long-term.
President Trump recently issued an executive order calling for the creation of a commission on chronic diseases, led by Mr. Kennedy, that would, among other things, investigate the “threat” posed by S.S.R.I.s to young people. The commission is set to deliver an initial report this month. Like many other physicians, I have reservations about the administration’s ability to rigorously study treatments, given its record of disregarding medical evidence and Mr. Trump’s preference for assigning leadership roles based on ideological loyalty rather than scientific credentials. With the National Institutes Health enfeebled by staff cuts and stalled grants, private research funding organizations need to step up and make the study of medication safety a research priority.
The public deserves advice about psychiatric medications that does not oscillate between stupor and alarmism. Antidepressants, like all medical interventions, come with benefits and trade-offs. If psychiatry refuses to engage seriously with patients’ concerns, if the mantra of “safe and effective” is all it is willing to publicly say, it will lose credibility. We cannot disregard those whose lives have been derailed by psychiatric medications.
This political era has revealed that the aggrieved would rather burn the system to the ground than put up with an establishment that does not speak to their everyday realities. The question is whether the medical establishment will meet that demand with humility and scientific transparency — or leave the conversation to those willing to exploit the suffering of vulnerable individuals for their personal and political gain.
Awais Aftab is a psychiatrist who runs the newsletter Psychiatry at the Margins and is the author of “Conversations in Critical Psychiatry.”
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