As a psychiatrist I have prescribed every type of antidepressant in every possible way. I have prescribed them before psychological therapy, so that people would feel well enough to start; and after, because therapy alone was not enough. I have supported patients through the first weeks of treatment, through the process – sometimes the struggle – to find the right dose or the right drugs, and through the process of stopping, once they are well enough.
What I have learned in my almost 30 years as a practitioner is that no two people take antidepressants in the same way, even when following the recommendations given to them. As with all medications, they don’t work for everybody and when they do, they work with different efficacy and different adverse effects. But they do very often work.
It is surprising to me that medications that have helped so many people with depression are also criticised with such vitriol by some voices in the clinical and mental health communities. Over the years, a vocal minority has launched a war on antidepressants, promoting the unscientific views that antidepressants do not work, and that depression is not a real illness. Discussion and proper interrogation of medical practices and prescribing protocol should be welcomed, but the debate around antidepressants in recent years has been unnecessarily divisive, with personal attacks upon scientists, physicians and even patients (when they defend their successful use of antidepressants) on social media.
This war has been long-running, and usually it is fought using methodologically sound studies to draw the wrong conclusions. For example, a famous study published in Plos Medicine in 2008 claimed that antidepressants work, but that the benefit is so small that they should not be used. (I argue against this point later on.) Other times the research is weak. A paper published in Molecular Psychiatry in July 2022 denied the role of the brain chemical serotonin in depression. It was criticised in June 2023 in the same journal for “substantial methodological weaknesses” by 35 international clinicians and scientists, including myself: a row that was reported in the Daily Mail, iNews and other outlets.
Unrelated, but indicative of the same criticisms against antidepressants, two BBC documentaries also aired last summer. They focused exclusively on the adverse effects of these medications (and especially on troublesome but rare effects, such as persistent sexual dysfunction), with little discussion of their benefits.
Yes, not everybody is helped by antidepressants, and yes, some people suffer from severe adverse effects. But the same is true of many medications. The key is to prescribe them to those who really need them and in the correct way, not to fight their use entirely. To leave people without access to medicines that can be life-saving is not an option in psychiatry, just as it is not an option in other branches of medicine. Any other position only increases the stigma against mental disorders.
When antidepressants can help
The number of adults prescribed antidepressants in England in 2022 has increased to 8.3 million (or 18 per cent of the adult population in England) compared with 7.9 million the year before. Some people argue that this indicates “overprescribing”, otherwise described (inappropriately) as “handing out antidepressants like sweets”. These statements, besides being patronising towards the people who take antidepressants who are actively participating in the decisional process and not passively ingurgitating whatever is offered to them, are also simply not true.
Antidepressants are not prescribed to people who are just sad. We have all been sad, sometimes for weeks. We have all felt overwhelmed, exhausted, unable to cope with what life throws at us. This is not being depressed (although depression might start that way). Most people in this situation – the 6 in 7 people who will never experience an episode of depression in their lives – find ways of coping with distress through personal resilience and social support. Antidepressants should not be – and are not – prescribed just for sadness.
Depression is different. The sadness is persistent, for weeks or months, and is accompanied by a lack of hope that things will ever get better or could be helped. It brings disrupted sleep and appetite, reduced energy and inability to feel pleasure. And it also impacts the way people live. A person may become unable to work, to have a social life, to look after themselves or their family. It may lead to social isolation, alcohol abuse or self-harm. These are people with “clinical depression”. These are the people to whom we prescribe antidepressants.
The current prevalence of clinical depression in Great Britain is at 16 per cent, two-thirds higher than before the pandemic, and worsened by the loss of welfare support and the cost of living crisis. So, it is not surprising that 18 per cent of adults in England are on antidepressants, given that some will be prescribed these medications for other diagnoses, such as anxiety or even pain.
I agree that some people on antidepressants would be better helped by social, financial or psychological support (which is often difficult to come by), rather than by medications. Yet there are also people with clinical depression who do not take antidepressants, at the appropriate dose and for the appropriate duration, because they cannot access help in the overstretched NHS, or because they are unwilling to seek help due to stigma associated with mental health problems.
Research conducted by the World Health Organization close to 20 years ago showed that only one in five people with depression received adequate treatment in high-income countries (and only 1 in 27 in low- and middle-income countries). The mental health charity Rethink has suggested that the more recent rise in antidepressant prescriptions indicates that people feel more comfortable in seeking help. Let’s hope so.
The evidence base
Let me clarify a few points. First, antidepressants do work. For many years, my only personal testimony was the smiles slowly returning to the faces of the people I was helping, after one or two months on antidepressants. But now you can read about it in the media. In response to a wave of criticisms of antidepressants in 2018, readers wrote to The Guardian to share their positive experiences of antidepressants. One reader wrote about recovering from “the desperate state of fear, anxiety and hopelessness. This is not to deny that counselling and other alternative treatments have their place. Drugs work for me.” People also responded to the two BBC documentaries aired last summer: Disclosure’s “Are My Antidepressants Worth It?” and Panorama’s “The Antidepressant Story”. The Mail on Sunday’s Eve Simmons wrote that she had been prescribed antidepressants on three occasions, the first when she was just 15 years old, and that “the experiences have been overwhelmingly positive”. The hashtag #pillshaming brought together yet more people reclaiming the validity of their positive experience with antidepressants.
Research strongly supports this experience. Meta-analyses (a statistical approach that puts together many studies) have clearly shown that antidepressants improve symptoms of depression compared with a placebo “dummy pill”. Of course, they are not miracle drugs, and many people, possibly up to one third, are not fully helped by currently available antidepressants. But they are not better or worse than other drugs we use in medicine. For example, their efficacy is better than medications used for hypertension and cardiovascular disorders, but worse than medications for migraine and asthma. Medicine is not perfect: people respond differently to the same drugs, and all the medications that we have across all of medicine are blunt, insufficient tools with plenty of adverse effects. Does that mean we should throw all medications out of the window?
Second, antidepressants reduce the risk of self-harm and suicide in adults and older people. Every 40 seconds, a suicide takes place somewhere in the world. While not all people who die by suicide have a mental disorder, depression is the leading cause of death by suicide, and depressed people have a 20-fold increased risk of taking their own life compared with the general population. Surely, we must do something to reduce this.
Understanding the association between antidepressants and suicide is difficult and requires the integration of evidence from different types of studies, from analyses of historical trends in the general population to comparisons between antidepressants and placebo. Putting together all the evidence, the consensus is that antidepressants protect against suicide in adults over 25 and even more in older people. As the risk of suicide is highest in adults – for example, in England it is highest among people aged 45-54 – there is no doubt that antidepressants are protective against suicide.
Importantly, antidepressants may increase the risk of suicide in adolescents and young people, although not all studies have confirmed this. Young people are more sensitive to mental and physical agitation induced by anti-depressants, which in some individuals may lead to self-harm. This explains the recommendation that antidepressants should not be routinely used by young people, and, if they are, they should be used under specialist supervision. One of the aforementioned BBC documentaries reported the tragic story of a young person who took his life after starting an antidepressant; while these are devastating events, they are also extremely rare.
Finally, most people can successfully stop antidepressants through a slow reduction of doses over a few weeks. Not all, but most can. We now have a better appreciation of the unpleasant sensations that people experience when stopping antidepressants, known as “withdrawal symptoms”. These are different from pre-existing symptoms of depression and include flu-like symptoms like shivering, excessive sweating and headache, as well as shock-like sensations described by some patients as “brain zapping”, insomnia and vivid dreams. They usually start within a few hours or days of stopping the antidepressant abruptly, and are greatly reduced by slowly stopping over time, ideally 2-4 months. These medications should never be stopped abruptly and without the support of a doctor. Some people will find stopping antidepressants very difficult and will require a longer and slower reduction of the dose over time.
As withdrawal symptoms are particularly troubling if people have been taking antidepressants for many years before they attempt to stop them, the next important question is: for how long should people take antidepressants?
When to stop
The guidelines are clear. People at their first episode of depression, or who experience a second episode many years after their first, should continue to take antidepressants for 6-9 months after they begin to feel noticeably better. As the improvement may take 2-4 months from the beginning of treatment to consolidate, close to one year of continuous treatment in most people would not be considered excessive, but they should then stop the antidepressants. People who experience more frequent episodes may require a longer period of treatment, usually for up to two full years of sustained wellbeing, before stopping. At the extreme end, there are those people with a continuous course of depression that returns every time antidepressants are stopped.
There is a real concern that people in the UK might be taking antidepressants for longer than is recommended, and the guidelines now underline the importance of continuous discussion between doctors and patients about stopping the medication. However, it is important to remember that these are collaborative decisions, and that people on antidepressants will ultimately make their own choices. Even if encouraged to stop by the doctors, they may prefer to continue a medication that has brought them back from a dark period in their lives. It requires strong motivation, on both the doctors’ and the patients’ side, to rock a boat that is successfully sailing and leaving a terrifying tempest behind.
And some of these people would be right to fear depression returning. A study published in 2021 in The New England Journal of Medicine investigated people who had been on antidepressants for at least two years, had recovered from their most recent depressive episode and felt well enough to consider stopping antidepressants. Those who stopped had double the risk of relapsing into depression during the subsequent year compared to those who continued with the drugs.
One of the criticisms still levelled at psychiatrists as part of the war on antidepressants is that our prescribing benefits “Big Pharma”. This was certainly true in the 1980s-90s, when the launch of selective serotonin reuptake inhibitors like Prozac (truly safer and more tolerated than the previously available antidepressants) was accompanied by an aggressive marketing strategy and generated billions for the industry. However, fast forward 30 years, and all major pharmaceutical companies have disinvested from mental health, and virtually all anti-depressants that we prescribe are produced by small generic companies, not by “Big Pharma”. They now cost very little: for example, the cost of Prozac dropped from approximately £30 per month to £1.50 per month when generic versions became available.
I am not saying that pharma has not influenced the market, or public and professional opinions in the past. But I am saying that this is not the reason we, as doctors, prescribe antidepressants or defend their clinical use today. We are doing this because, in good faith and based on strong clinical evidence, we know that they work and help people.
Depression is a real illness, with real physical causes. There have been hundreds of studies proving that the brain and the body of a person with depression show clear and reproducible changes. Changes in the size and function of brain areas, visible with live brain imaging; changes in the shape and number of brain cells, visible on a microscope; changes in hormones, inflammation and metabolic function, visible with blood tests; changes in the way the heart and the gut work. The fact that societal factors contribute to depression does not make it less real.
Those attacking the use of antidepressants may have their hearts in the right place, but they need to become aware of the devastating consequences of the climate of doubt they help to create, which is hurting the most vulnerable in our society. It creates a perception that the people, rather than the illness, are to be blamed for their difficulties. It deepens and widens the chasm between mental and physical health, at the expense of the first. It prevents people with depression from taking the medications they need, or may push them into stopping antidepressants prematurely. It fosters blame and suspicion. It demoralises the clinicians who are helping people with depression. Above all, it increases the stigma against all patients with psychiatric disorders, affecting their motivation to seek help. This must stop now.
Carmine Pariante is professor of psychiatry at King's College London and an officer of the British Association for Psychopharmacology.
Author's disclosure statement: While more than 90 per cent of my research funding comes from UK and EU governments and charities, I have received some research funding from pharmaceutical companies interested in antidepressants, as publicly declared in all of my scientific papers.
This article is from New Humanist's winter 2023 issue. Subscribe now.
