A Realistic Comparison of SSRI and Heroin WIthdrawal

With all the quotes in the media about these withdrawal syndromes – I thought I would add a few facts.  These facts are based on science, my 22 years in acute care psychiatry, and another decade at a large facility specializing in substance use disorders.  I have been involved in the care of thousands of people with these disorders, and the care has improved substantially over that period of time largely due to the availability of Medications for Opioid Use Disorder (MOUD).  Before that there was a major problem treating anyone with an Opioid Use Disorder (OUD) if they were not enrolled in a methadone maintenance program. 

To cite a few examples, in acute care psychiatry it is common to receive emergency admissions of people with severe depression or psychosis.  Many have associated drug and alcohol problems.  In the case of heroin and other opioids, there was a rule extending up into the early 2000s that unless a person was enrolled in a methadone maintenance program, only acute detox could be done with methadone.  Additional medications were offered like clonidine to cover hyperadrenergic symptoms of opioid withdrawal.  Clonidine was often the only detox medication. The situation was not better in substance use disorder (SUD) treatment programs who often had an array of “comfort medications” designed to treat all of the peripheral symptoms of withdrawal.  The problem with this approach was twofold: first it was rarely adequate to treat acute withdrawal. Second, when the patient was discharged in a week, they had ongoing symptoms of withdrawal that essentially guaranteed an immediate relapse to opioid use.

The introduction of buprenorphine (Suboxone, Subutex, Sublocade) resulted in a marked improvement in the quality of care in this scenario. The acute and chronic withdrawal symptoms of opioids could be adequately treated and the risk of relapse mitigated. During the time of this transition, the large SUD treatment center where I was working went from using buprenorphine for acute detox to buprenorphine maintenance treatment.  I was responsible for treating depression and anxiety in these patients.  I observed that no matter what treatment I prescribed the anxiety, insomnia, irritability, and depression persisted for months as protracted opioid withdrawal symptoms until they were treated with buprenorphine.  At that point the withdrawal symptoms resolved immediately and completely.  The depression, anxiety, insomnia, and craving for opioids all resolved.  That massive improvement in care cannot be emphasized enough.  I went from discharging people after 1-3 months who I knew would relapse immediately to confidently discharging people who were stable and had a much better chance to recover.

I am posting this introduction because the historical window for this innovation was very brief and I doubt that many physicians ever saw it.  The advantage for patients was so clear that the medical director of the treatment program where I worked changed it from an abstinence-based program to MOUD.  The research at the time was clear.  MOUD saved lives by decreasing relapse rates, accidental overdoses, and decreased risk of infections (HIV, HCV).

In my previous post, I examined the rhetoric of comparing selective serotonin reuptake inhibitor (SSRI) withdrawal to heroin withdrawal.  But what about the popular myths and the science?  The popular view of opioid withdrawal is that once the acute phase is over – it is over.  The popular view promoted with SSRI withdrawal is that it is typically universal, severe, and long lasting.  Neither of those views are accurate.

The time course of symptoms is outlined in the diagram at the top of this post.  Acute symptoms have a characteristic pattern and can start as soon as hours after a last dose of heroin.  In the case of antidepressants, the time course is more dependent on the mechanism of action and half-life of the medication being studied. Since opioids are all mu opioid receptor (MOR) agonists – there are no known medications in this class that do not cause withdrawal, but what accounts for the differences in severity and percentages of people affected is not known. Pharmacokinetics and pharmacodynamics likely play a role – I will defer that discussion to later post.

The main qualitative differences in opioid and SSRI withdrawal are the lack of cravings and observable physical symptoms in SSRI withdrawal.  Opioids reinforce their own use and for that reason have street values.  SSRIs do not and have no street value. The withdrawal symptoms from SSRIs are largely subjective but that does not mean they are not real or serious.  

In the case of SSRIs and other antidepressants, the mechanism precipitating withdrawal is thought to be a precipitous fall in extraneuronal serotonin.  All SSRIs are orthosteric inhibitors of the serotonin transport protein (SERT).  Orthosteric inhibitors act like serotonin at the same binding site on SERT.  Allosteric modulators bind at a site that is topographically distinct from the site that the endogenous ligand (in this case serotonin or 5-HT) binds to.  Escitalopram has an additional effect on SERT as an allosteric modulator.  Trazodone, vilazodone, and nefazodone are all allosteric non-competitive inhibitors of SERT (1-4).  Withdrawal reaction have been described by both but not to the same degree as heroin withdrawal.   

In the case of heroin withdrawal, a series of studies done from 1962 to 1969 showed very high relapse rates (>90%) in heroin users who had been treated in a controlled environment. Thise studies led to early experiments with MOUD and eventually methadone maintenance.  A direct comparison of the likelihood of moderate withdrawal symptoms for each category is 3-31% for SSRIs and 100% for opioids.   Those numbers are qualified by several caveats.  First, opioid withdrawal has been studied for a much longer time, is more well characterized, and fewer medications are involved.  Second, study methodology for the SSRI withdrawal is much more varied from looking at short term randomized controlled studies to surveys of long-term use selected for withdrawal symptoms.  The former will underestimate withdrawal effects but identify a drug attributable effect by subtracting out placebo and the latter will overestimate effects .  The overestimate can be compounded by not subtracting a nocebo effect and publicity effects that may increase nocebo.  In clinical practice, using antidepressants with lower withdrawal risk – I found the incidence to be closest to that of Henzler, et al (7) at about one in six or seven people.    

In conclusion, discontinuing many medications can cause a withdrawal syndrome. Not all withdrawal syndromes indicate an addiction and some can be life-threatening.  They are difficult to study for several reasons.  First, the response to discontinuing the medication varies significantly from person to person even at the same dose and duration of use. That range is significant from no effect to severe and in some cases (alcohol, sedative hypnotics) life-threatening effects.  That includes a placebo response where that can be safely implemented.  Second, there is also a lack of high-quality evidence for many of these syndromes. The best evidence is for alcohol and sedative hypnotics because they are obvious and have been treated for decades.  But even then there are consensus guidelines such as the ASAM guideline on benzodiazepine tapering.  Third, there is limited standardization across guidelines.  Fourth, there are pharmaceutical limitations.  In some cases, very small doses of medication are needed to complete the protocol that may require a liquid form, pill cutting, or substitution with an equivalent medication with a longer half-life.  In some cases, all of these changes may not be enough.  Fifth, in clinical trials where medications were tapered and discontinued there may not be enough reported details to replicate the protocol in clinical practice (5).  Sixth, the outcomes of discontinuation of a medication are complex and include resolution of adverse drug effects, relapse to the treated condition, a unique withdrawal syndrome, or a rebound effect involving the physiological systems that were being treated – like rebound tachycardia after stopping beta-blockers.  Seventh, context is important especially with medications and substances that reinforce their own use.  Adherence to any tapering protocol on an outpatient basis is much less likely to happen.  Eighth, the medicolegal dimension may be a concern.  Because of the all of these factors, there is a lot of uncertainty involved in any tapering and discontinuation protocol.  There is seldom a protocol that will work well for everyone. Because of this risk some guidelines advise clinicians to seek legal or administrative consultation when attempting these protocols.  There is additional risk if relapse to the original condition occurs after a medication has been successfully stopped.

Despite all these concerns tapering and discontinuing medications is foundational medicine in any medical specialty. None of these problems are unique to psychiatry or medication for mental disorders.  As interns most physicians learning how to detoxify acute care patients with substance use disorders – the most common condition remains alcohol use disorder.  In their respective specialties – they learn more about how to do this with specific medications used in their specialty. That has resulted in protocols that can differ from hospital to hospital in the same town. In some cases, the protocols differ in the same hospital over a period of years.  To cite one example, I am aware of a hospital that used oxazepam followed by diazepam and then chlordiazepoxide or phenobarbital as their detox agents from alcohol and benzodiazepines. In some of the standard orders, anticonvulsants were also used to minimize seizure risk.

As more societies and government agencies get involved there is a gradual move to standardization.   Even if we get to that point – individual assessments and close monitoring will still need to be done.  The risk of a withdrawal syndrome from any medication is one that is necessary to medically treat various problems.  It is a decision that physicians and patients do not take lightly.  It is important to discuss that potential risk in the informed consent discussion.    

 

George Dawson, MD, DFAPA

 

References:

1:  Plenge P, Yang D, Salomon K, Laursen L, Kalenderoglou IE, Newman AH, Gouaux E, Coleman JA, Loland CJ. The antidepressant drug vilazodone is an allosteric inhibitor of the serotonin transporter. Nat Commun. 2021 Aug 20;12(1):5063. doi: 10.1038/s41467-021-25363-3. PMID: 34417466; PMCID: PMC8379219.

2:  Sanchez C, Reines EH, Montgomery SA. A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int Clin Psychopharmacol. 2014 Jul;29(4):185-96. doi: 10.1097/YIC.0000000000000023. PMID: 24424469; PMCID: PMC4047306.

3:  El-Kasaby A, Boytsov D, Kasture A, Krumpl G, Hummel T, Freissmuth M, Sandtner W. Allosteric Inhibition and Pharmacochaperoning of the Serotonin Transporter by the Antidepressant Drugs Trazodone and Nefazodone. Mol Pharmacol. 2024 Jun 18;106(1):56-70. doi: 10.1124/molpharm.124.000881. PMID: 38769018.

4:  Murray KE, Ressler KJ, Owens MJ. In vivo investigation of escitalopram's allosteric site on the serotonin transporter. Pharmacol Biochem Behav. 2016 Feb;141:50-7. doi: 10.1016/j.pbb.2015.11.010. Epub 2015 Nov 24. PMID: 26621784; PMCID: PMC4724252.

5:  Dirven T, Turner C, Thio SL, Blom J, Muth C, van Driel ML. Room for improvement in reporting of trials discontinuing long-term medication: a systematic review. J Clin Epidemiol. 2020 Mar;119:65-74. doi: 10.1016/j.jclinepi.2019.11.013. Epub 2019 Nov 29. PMID: 31786152.

6:  Goldberg JF, McIntyre RS, Swartz HA, et al. American Society of Clinical Psychopharmacology Task Force on the Deprescribing of Psychotropic Medications. Recommendations for the Deprescribing of Psychotropic Medications: A Consensus Statement From the American Society of Clinical Psychopharmacology Task Force. JAMA Netw Open. 2026 Feb 2;9(2):e260043. doi: 10.1001/jamanetworkopen.2026.0043. PMID: 41739481.

7:  Henssler J, Schmidt Y, Schmidt U, Schwarzer G, Bschor T, Baethge C. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry. 2024 Jul;11(7):526-535. doi: 10.1016/S2215-0366(24)00133-0. Epub 2024 Jun 5. Erratum in: Lancet Psychiatry. 2024 Sep;11(9):e11. doi: 10.1016/S2215-0366(24)00253-0. PMID: 38851198.

 

 

 

 

The Politics of Deprescribing: Deconstructing the HHS Mental Health Agenda

Misinformation Claim	Status	References
Vaccines cause autism	Debunked conspiracy theory	1
SSRIs cause mass shootings	Debunked conspiracy theory	1
Diet replaces antipsychotics for schizophrenia	Debunked conspiracy theory	1
SSRIs are more addictive than heroin based on withdrawal symptoms	Debunked misinformation	2
Psychiatric medication overprescribing caused the crisis	Inverts the evidence (undertreatment is the problem)	2
Acetaminophen causes autism	Not supported by sibling-controlled analyses	3-4
MAHA targeting of specific drug classes in children	Misleading framing; omits actual chronic disease drivers	2, 5
MAHA Commission promoting distrust of mental health treatment	Documented concern in psychiatric literature	6
Nutrition/lifestyle as replacement for psychiatric treatment	"Promising" ≠ evidence-based alternative	2, 16
Omission of social determinants of mental health	Fundamental misattribution of the problem	7-8
Termination of NIH/NIMH grants to “reduce budget deficit” – no impact on budget but affects 70K research subjects	Misattribution of the problem and no impact on deficit	10-11
Government's own role in creating the crisis through underfunding	Ignored by HHS framing	12-13
Alcohol as a healthy beverage "In the best-case scenario, I don't think you should drink alcohol, but it does allow people an excuse to bond and socialize, and there's probably nothing healthier than having a good time with friends in a safe way." Mehmet Oz, MD - Administrator of the Centers for Medicare and Medicaid Services	-Debunked by study designed to update dietary guideline – no safe level of alcohol use. -Current dietary guideline contains a mix of recommendations from 1-2 drinks per day to “drinking less is better than drinking more”.	14,15
Executive Order 14321 (July 24, 2025), titled Ending Crime and Disorder on America's Streets, mandates that recipients of federal homelessness assistance require unhoused individuals—many of whom are living with substance use disorders and mental health conditions—to utilize rehabilitation and psychiatric services	-Housing first is ended – participation contingent on participation in treatment -Broadening civil commitment without adding to infrastructure to address homelessness - Does not address fact that both mental health and SUD homeless were constant and 43% increase was due to other factors - Does not address lack of affordable housing -Does not address continued lack of equity despite MHPAEA	17
Executive Order 14379 (January 29, 2026), titled Addressing Addiction Through the Great American Recovery Initiative, establishes a federal White House initiative to coordinate and prioritize national policies regarding addiction prevention, treatment, recovery support, and re-entry	-Harm reduction is modified to eliminate test strips for contaminants and medication (MOUD) only programs and annual tapering must be attempted. -Harm reduction label must be eliminated. -Provides administrative redundancy without actual increase in resources. -Effectively suspended the NSDUH survey used to track SUD and mental health trends in the USA -Sweeping cuts to the federal agencies tasked with carrying out this work—specifically targeting the Substance Abuse and Mental Health Services Administration (SAMHSA)	18
Executive Order 14401 (April 18, 2026), titled Accelerating Medical Treatments for Serious Mental Illness, directs the FDA and HHS to expedite research and approval for innovative psychedelic therapies (such as ibogaine and psilocybin) to treat conditions like PTSD, depression, and addiction.	-Harm reduction is modified to eliminate test strips for contaminants and medication (MOUD) only programs and annual tapering must be attempted. -Harm reduction label must be eliminated -Significant safety concerns with underreporting of side effects in many of these studies -Lack of necessary infrastructure with intense staffing to provide psychedelic therapies -Immediate access to investigational psychedelics under “right to try” laws.	19-23
HR 1 /One Big Beautiful Bill Act (OBBBA)versus Executive Orders 14321,14379, and 14401 - Mandated treatment while drastically cutting resources. -false accusations of abuse of the system -tax cuts for the wealthy rationalized as budgetary necessity - Medicaid is the nation's largest payer of mental health and substance use disorder care -Medicaid is the primary intervention to address social determinant of healthcare (SDOH). -Medicaid is the largest single payer of pregnancy related services and maternity care in the US. (40% of all pregnancies)	- would increase the number of uninsured by 7.6 million and cause an estimated 16,642 medically preventable deaths annually to 16 million newly uninsured would lead to over 140 000 additional deaths. - cuts taxes by $4.5 trillion over the next decade and partly pays for it with $911 billion in Medicaid spending cuts. -92% of Medicaid recipients already work and meet eligibility requirements. -disproportionate impact on rural communities, black and Hispanic, perinatal care, and substance use treatment. - Medicaid cuts threaten emerging infrastructure that directly addresses social determinants of health (SDOH) — including food insecurity, housing instability, and transportation barriers while worsening the very social conditions that drive poor health outcomes. -55-66% of people say affordability restrict access to MH and SUD care and 65-72% say they have limited access. -based on previous cuts in healthcare spending the magnitude of harms may be underestimated -	24-29
1:  Shim R. Conspiracy Theories Are Incompatible With Effective Health Policies. JAMA Health Forum. 2026;7(4):e261472. doi:10.1001/jamahealthforum.2026.1472 2:  Rubin R. HHS Says Psychiatric Medications Are Overprescribed, but Are They? JAMA. Published online June 26, 2026. doi:10.1001/jama.2026.8946 3:  Gostin LO, Wetter SA, Lurie P. Can a New Commission Make America Healthy Again? JAMA Health Forum. 2025;6(3):e251304. doi:10.1001/jamahealthforum.2025.1304 4:  Cortese S. Pharmacologic treatment of attention deficit–hyperactivity disorder. New England Journal of Medicine. 2020 Sep 10;383(11):1050-6. 5:  Greenhill LL, Pliszka S, Dulcan MK, et al. American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002 Feb;41(2 Suppl):26S-49S. doi: 10.1097/00004583-200202001-00003. PMID: 11833633. 6:  Smith WR, Sharfstein SS, Appelbaum PS. The Make America Healthy Again Commission and Mental Health Distrust. Psychiatr Serv. 2026 Jan 1;77(1):70-73. doi: 10.1176/appi.ps.20250228. Epub 2025 Oct 30. PMID: 41163425. 7:  Alegría M, Alvarez K, Cheng M, Falgas-Bague I. Recent Advances on Social Determinants of Mental Health: Looking Fast Forward. Am J Psychiatry. 2023 Jul 1;180(7):473-482. doi: 10.1176/appi.ajp.20230371. PMID: 37392038; PMCID: PMC12096341. 8:  Cotton NK, Shim RS. Social Determinants of Health, Structural Racism, and the Impact on Child and Adolescent Mental Health. J Am Acad Child Adolesc Psychiatry. 2022 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020. Epub 2022 May 6. PMID: 35533798. 9:  Patel VR, Liu M, Jena AB. Clinical Trials Affected by Research Grant Terminations at the National Institutes of Health. JAMA Intern Med. 2026 Jan 1;186(1):126-128. doi: 10.1001/jamainternmed.2025.6088. PMID: 41247710; PMCID: PMC12624462. 10:  Jalali MS, Hasgul Z. Potential Trade-Offs of Proposed Cuts to the US National Institutes of Health. JAMA Health Forum. 2025;6(7):e252228. doi:10.1001/jamahealthforum.2025.2228 11: U.S. Department of the Treasury. Fiscal Service, Federal Debt: Total Public Debt [GFDEBTN], retrieved from FRED, Federal Reserve Bank of St. Louis; https://fred.stlouisfed.org/series/GFDEBTN, July 14, 2026 12:  Jeste DV, Gyan E. Social Determinants of Health in Psychiatric Disorders: Exciting Opportunities for Biopsychosocial Research and Clinical Care. Am J Psychiatry. 2026 Jul 1;183(7):450-460. doi: 10.1176/appi.ajp.20260402. Epub 2026 Jul 1. PMID: 42380754. 13:  Baird S, Choonara S, Azzopardi PS, et al. A call to action: the second Lancet Commission on adolescent health and wellbeing. Lancet. 2025 May 31;405(10493):1945-2022. doi: 10.1016/S0140-6736(25)00503-3. Epub 2025 May 20. PMID: 40409329. 14:  George S, Naimi TS, Keyes K, et al. Alcohol Intake and Health Study: No Protective Effect at Low Levels, With Mortality Increasing to 1 in 25 at 14 Drinks Per Week. J Stud Alcohol Drugs. 2026 Jul;87(4):621-638. doi: 10.15288/jsad.25-00435. PMID: 42420014. 15:  Dietary Guidelines for Americans, 2025-2030:  https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf 16:  Walrath-Holdridge M. RFK Jr. says keto can 'cure' schizophrenia. Can a diet alleviate mental illness?  USA Today Feb 19, 2026:  https://www.usatoday.com/story/news/health/2026/02/19/rfk-jr-keto-diet-cure-schizophrenia/88739528007/ 17:  Saunders H, Rudowitz R.  A Look at the New Executive Order and the Intersection of Homelessness and Mental Illness.  KFF.  August 15, 2025:  https://www.kff.org/mental-health/a-look-at-the-new-executive-order-and-the-intersection-of-homelessness-and-mental-illness/ 18:  Panchal N, Saunders H.   Tracking Key Mental Health and Substance Use Policy Actions Under the Trump Administration.  KFF.  July 10, 2026: https://www.kff.org/mental-health/tracking-key-mental-health-and-substance-use-policy-actions-under-the-trump-administration/ 19:  Cohen IG, Lynch HF, McGuire AL. The Psychedelic Therapies Executive Order: On Approval and Clinical Readiness. JAMA. Published online July 01, 2026. doi:10.1001/jama.2026.11892   20: Hinkle JT, Graziosi M, Nayak SM, Yaden DB. Adverse Events in Studies of Classic Psychedelics: A Systematic Review and Meta-Analysis. JAMA Psychiatry. 2024;81(12):1225–1235. doi:10.1001/jamapsychiatry.2024.2546  21:  Ghaznavi S, Ruskin JN, Haggerty SJ, King F 4th, Rosenbaum JF. Primum Non Nocere: The Onus to Characterize the Potential Harms of Psychedelic Treatment. Am J Psychiatry. 2025 Jan 1;182(1):47-53. doi: 10.1176/appi.ajp.20230914. PMID: 39741443. 22: Brunt TM. Rare but relevant: Ibogaine and cardiovascular complications-prolonged QT interval and ventricular arrhythmias. Addiction. 2026 Jun;121(6):1616-1621. doi: 10.1111/add.70319. Epub 2026 Jan 20. PMID: 41560340; PMCID: PMC13155281. 23: Edwards EP, Gray LA, Elamin MEMO, Veiraiah A, Thanacoody RHK, Coulson JM. A case series of ibogaine toxicity reported to the United Kingdom National Poisons Information Service (NPIS) over a 10-year period. Clin Toxicol (Phila). 2025 Mar;63(3):212-216. doi: 10.1080/15563650.2024.2447500. Epub 2025 Jan 30. PMID: 39882933.  24:  Gaffney A, Himmelstein DU, Woolhandler S. Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health. Ann Intern Med. 2025 Sep;178(9):1334-1342. doi: 10.7326/ANNALS-25-00716. Epub 2025 Jun 17. PMID: 40523288. 25:  Cutler DM. The Worst Piece of Health Care Legislation Ever. JAMA Health Forum. 2025;6(8):e254626. doi:10.1001/jamahealthforum.2025.4626 26:  Gaffney A, McCormick D, Bor D, Himmelstein DU, Woolhandler S. What Happens When Coverage is Cut? Looking Backward and Forward From the One Big Beautiful Bill. Milbank Q. 2026 Jun;104(2):324-360. doi: 10.1111/1468-0009.70082. Epub 2026 Apr 30. PMID: 42063224. 27:  Frank RG. Medicaid Reforms in the One Big Beautiful Bill Act and Mental Health Care. Psychiatr Serv. 2026 Jun 24:appips20260012. doi: 10.1176/appi.ps.20260012. Epub ahead of print. PMID: 42337436. 28:  Lin Y, Li H, Nahata MC, Zhang C, Ramey OL, Liu L. Treatment Patterns and Barriers to Care Among U.S. Adults With Co-Occurring Substance Use Disorder and Mental Illness. Am J Psychiatry. 2026 Jul 8:appiajp20251314. doi: 10.1176/appi.ajp.20251314. Epub ahead of print. PMID: 42415254. 29: Berkowitz SA, Archibald J, Yu Z, et al. Medicaid Spending and Health-Related Social Needs in the North Carolina Healthy Opportunities Pilots Program. JAMA. 2025;333(12):1041–1050. doi:10.1001/jama.2025.1042

Since May 2026, Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has promoted an initiative to restructure U.S. mental health delivery. The plan heavily emphasizes "prevention and holistic treatments" while actively discouraging the use of psychiatric medications, under the premise that they are widely overprescribed—especially in children.

A May 4, 2026 memo outlines the core strategy: addressing the "mental health crisis" by making deprescribing (tapering and discontinuing medications) and annual pharmacological reviews reimbursable services, alongside launching federal webinars to teach clinicians how to taper patients off medications.

While these proposals may sound progressive to the public, they collapse under scientific scrutiny for three primary reasons.

1. The Myth of Overprescribing

The administration's central premise—that the mental health crisis is driven by overmedication—is medically inaccurate.

• The Reality of Undertreatment: Up to 23% of the U.S. population has a treatable psychiatric condition warranting antidepressants, yet only a fraction of those individuals receive a prescription.  An estimated 90–95% of suicide decedents had a diagnosable psychiatric disorder, but postmortem toxicological screening consistently finds antidepressants in only 12–29% of cases, with particularly low detection rates among men and younger individuals.  Nearly half of suicide decedents had at least one recently dispensed medication undetected at autopsy, directly evidencing non-adherence. 

  [3]Discontinuation of antidepressants is associated with a 1.6-fold increased risk of suicide attempt compared to continued therapy, and the first 28 days after both starting and stopping antidepressants represent periods of peak vulnerability. [4-5] At the population level, higher SSRI prescribing rates correlate inversely with national suicide rates, supporting the premise that adequate antidepressant treatment confers a protective effect. [6] These findings suggest that the problem is not antidepressant exposure but the failure to initiate, maintain, and monitor adequate pharmacotherapy in individuals with depression who are at risk for suicide (15-19). [7-8]

• Non-Psychiatric Indications: Antidepressants are heavily prescribed for non-psychiatric, FDA-approved or clinically indicated conditions, including migraines, tension headaches, chronic pain, fibromyalgia, and smoking cessation. Studies show that 50% to 64% of all antidepressant prescriptions are written for these non-psychiatric diagnoses [4-8].

• The Gap: When accounting for these physical health prescriptions, only about a quarter of Americans who actually need antidepressants for psychiatric conditions are receiving them. The real crisis is undertreatment, not overmedication [11-13]. Primary care settings miss or misdiagnose depression 40% to 50% of the time, and there is a 90% gap between individuals diagnosed with depression and those receiving clinically effective treatment [14].

2. Redundant "Solutions" to Standard Medical Training

The proposal to have HHS educate doctors on tapering is highly redundant and ignores existing clinical infrastructure.

• Tapering and Discontinuing Medication is Foundational Medicine: Psychiatrists and primary care physicians are already trained in tapering and discontinuing medications. Clinicians have been acutely aware of antidepressant discontinuation syndrome since the first case report in 1959, and it has been standard textbook material since at least 1993.

• Complex Cross-Tapering: In practice, stopping a medication rarely happens in a vacuum. Clinicians routinely manage highly complex transitions—such as cross-tapering (stopping one drug while initiating another) or managing patients who arrive with shopping bags full of conflicting medical and psychiatric prescriptions.

• Existing Resources: Detailed clinical guidance on switching and stopping antidepressants has been readily available in industry-standard databases like UpToDate for over 18 years [9,10]. Rather than funding political webinars, a far more effective HHS initiative would be providing free UpToDate access to all practicing U.S. clinicians.

• Routine Care vs. Political Incentives: Assessing medication efficacy, side effects, and whether to continue, adjust, or stop a drug is already a mandatory component of every standard psychiatric visit. Rebranding this routine care as a newly incentivized "deprescribing service" is purely rhetorical.

3. The Clinical Danger of Forced Deprescribing

Both the American Psychiatric Association (APA) and the American Foundation for Suicide Prevention (AFSP) have issued sharp responses to the HHS initiative:

• The APA strongly objects to defining the mental health crisis as an issue of "overprescribing."

• The AFSP warns that aggressive, medically unsupported "deprescribing" carries severe risks, including increased all-cause mortality, cardiovascular mortality, suicidal behavior, completed suicides, decreased quality of life, and long-term disability.

The Double Standard: Fast-Tracking Psychedelics

While the administration seeks to restrict standard, rigorously studied psychiatric medications, it simultaneously pushes to expedite the review and approval of innovative psychedelics (e.g., psilocybin, noribogaine, and methylone/MDMC) under "Right to Try" laws [19-23].

This presents a glaring policy contradiction:

• High Risks: These compounds carry documented risks of severe psychiatric, cardiac, and systemic side effects (such as QT interval prolongation and arrhythmias linked to ibogaine) [22,23].

• No Infrastructure: Administering psychedelic therapy safely requires intensive, highly staffed clinical infrastructure that the current healthcare system does not possess and likely will never adequately fund.

• Hypocrisy: It is ideologically inconsistent to demand less medication use while fast-tracking high-risk, under-studied substances with relaxed regulatory oversight.

The Broader Landscape of Public Health Misinformation

The antidepressant initiative is part of a broader, systemic pattern of health policy distortion outlined below (and in the lead table):

Scientific Debunking vs. Public Policy (from lead table)

Misinformation Claim	Scientific & Empirical Reality	Citation(s)
Vaccines cause autism	Long-debunked conspiracy theory; actively promoted by RFK Jr. to undermine public trust in vaccines.	[1]
SSRIs cause mass shootings	Debunked. Mass shootings correlate heavily with firearm density, not antidepressant use. Meanwhile, the administration is actively rolling back firearm restrictions for the mentally ill.	[1]
Diet/Keto replaces schizophrenia meds	No clinical evidence supports this. While RFK Jr. claims a ketogenic diet can "cure" schizophrenia, medical consensus remains that clozapine and standard antipsychotics are the gold standard.	[2, 16]
SSRIs are more addictive than heroin	Scientifically false statements made by RFK Jr. during his confirmation hearings. Retraction was formally demanded by 25 members of Congress in March 2025.	[2]
Acetaminophen causes autism	Not supported by rigorous sibling-controlled genetic analyses.	[3, 4]
Alcohol is a healthy social beverage	Promoted by CMS Administrator Mehmet Oz. Directly debunked by modern dietary analyses showing no safe level of alcohol consumption.	[14, 15]

The Policy Fallout: Cutting Resources While Mandating Treatment

The administration's legislative agenda, highlighted by H.R. 1 / One Big Beautiful Bill Act (OBBBA) and Executive Orders 14321, 14379, and 14401, represents a systematic defunding of the mental health safety net under the guise of reform.

1. The Homelessness Mandate (EO 14321)

This order effectively ends "Housing First" policies by making federal housing assistance contingent upon unhoused individuals entering mandatory psychiatric and substance use treatment [17].

• The Error: It ignores the reality that homelessness increases are driven primarily by a lack of affordable housing, not sudden spikes in mental illness.

• No Support: It broadens civil commitment powers without building the clinical infrastructure or beds needed to house or treat these individuals.

2. Dismantling Harm Reduction (EO 14379 & 14401)

The "Great American Recovery Initiative" restructures national addiction policy by stripping away proven harm reduction tools [18].

• The Damage: It bans the distribution of fentanyl test strips, defunds medication-assisted treatment (MOUD) programs that do not force annual drug tapering, and bans the very term "harm reduction" from federal programs.

• Data Blackout: It effectively suspended the National Survey on Drug Use and Health (NSDUH), blinding researchers to national addiction and mental health trends, while imposing sweeping budget cuts on SAMHSA.

3. Stripping Medicaid (OBBBA / H.R. 1)

Medicaid is the nation's largest payer of mental health and substance use disorder care, and the primary funding vehicle for addressing Social Determinants of Health (SDOH) (housing, food security, and transportation) [24-29].

• The Cuts: The bill slashes $911 billion from Medicaid over the next decade to offset $4.5 trillion in tax cuts.

• The Toll: Economists estimate these cuts will strip health coverage from 7.6 million to 16 million Americans, resulting in 16,642 to over 140,000 medically preventable deaths annually [24,26].

• The Demographics: These cuts disproportionately harm rural communities, Black and Hispanic populations, perinatal care, and those seeking addiction treatment—all while 92% of Medicaid recipients already meet work and eligibility requirements.

Conclusion: Rhetoric Over Reality

When health policy is systematically distorted, we must look at the underlying political strategy. The current administration relies heavily on creating rigid in-groups and out-groups, framing public health officials, scientists, academics, and social advocates as "enemies" who are oppressing their core demographic.

The HHS antidepressant and "deprescribing" initiative is not a sincere effort to improve clinical care. It is a rhetorical distraction. By framing the mental health crisis as a personal failure of "overprescribing" doctors and "drugged" citizens, the administration conveniently avoids addressing the structural, economic, and social determinants of health—all while actively dismantling the financial and clinical infrastructure that keeps vulnerable Americans alive.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  Not loving the table.  I tried everything possible to convert my 4 page Word table that is the basis for this post to a single continuous image.  I also tried pasting it directly into this post without any success.  The table alone was too large for the Blogger format and I could not find any way in the HTML to modify the size.  The expected continuous images were too narrow and I could not resize them.  Until I find a way - just click on each table page and it is readable.  The references in the table are in the table and not at the bottom of the post.

Supplementary 2:  A reader pointed out that RFK never explicitly said that SSRIs are “more addictive than heroin.”  That is a common paraphrase and I think if you read any of the following direct quotes it is easy to see how people come to that conclusion. Further his “expertise” only gets him so far.  I happen to be trained in addiction psychiatry and it is a common misconception that opioid withdrawal is miserable but it is over in 4 or 5 days.  In fact, it can persist for 6 months or longer with prominent symptoms of insomnia, anxiety, depression, and cravings that do not respond to usual care.  Those symptoms do respond to Medications for Opioid Use Disorder (MOUD) and it is the main reason that those medications are effective in preventing relapse and accidental overdoses. More details in the next post on this blog. See direct quotes and sources below:    

Direct RFK quotes:

1:  "I happen to be an actual expert on this, because I was addicted to heroin for 14 years... I've watched people come off of SSRIs and it is, it's not even comparable."

 – RFK Jr talks heroin addiction, SSRI views in speech to MAHA.  USA Today May 5, 2026.

2:  “Kennedy reiterated earlier remarks that heroin is easier to come off of than antidepressants. "I happen to be an actual expert on this because I was addicted to heroin for 14 years," he said. He then appeared to get teary speaking about a family member he said was suicidal while she withdrew from an antidepressant. "I've heard that from hundreds and hundreds of people," he said.” 

White LE, McKay B. RFK Jr. Wants to Wean Some Americans Off Antidepressants; HHS will encourage doctors to consider lifestyle changes, not drugs, to treat depression Wall Street Journal. May 4, 2026.

3: .RFK Senate Confirmation Hearing January 30, 2025 direct excerpts

 “Exactly, and that's the solution. 15% of American youth are now on Adderall or some other ADHD medication. Even higher percentages are on SSRIs and benzos. We are not just over medicating our children, we are over medicating our entire population. Half the pharmaceutical drugs on earth are now sold here. 70% of the profits from pharmaceutical companies are from the United States, even though we only have 4.2% of the world's population. Not only that, but a recent study by Cochrane collaboration founder Peter Gøtzsche found that pharmaceutical drugs are the third-largest cause of death in our country after heart attacks and cancers. They're not making us healthier. We need community health initiatives. We need access to treatment, we need exercise, we need better food

“They should have the availability. Listen, I know people, including members of my family, who've had a much worse time getting off of SSRIs than people have getting off heroin. The withdrawal period is… And it's written on the label. It's all documented.”

4:  Address to MAHA Institute May 2026:

“The United States does not just face a mental health crisis, we face a dependency crisis. Driven by overmedicalization. The data is clear. 1 in 6 American adults takes an antidepressant, 1 in 10 children are on prescription medication for their mental health. 30% of college students report using psychiatric medications in the past year, and in nursing homes, more than half of the residents are on prescribed antidepressants.”

References:

1:  WTAS: HHS Launches MAHA Action Plan to Curb Psychiatric Overprescribing.  https://www.hhs.gov/press-room/wtas-hhs-launches-maha-action-plan-curb-psychiatric-overprescribing.html

An embarrassing collection of attention seekers and compromisers.  Note how the APA position reads compared with the link above.

2: Centers for Medicare & Medicaid Services.  The Mental Health Parity and Addiction Equity Act (MHPAEA): https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity  (accessed 07/13/2026)

3: Kessler, Glenn (January 23, 2021). "Trump made 30,573 false or misleading claims as president. Nearly half came in his final year". The Washington Post. Archived from the original on January 24, 2021.

4:  Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Aff (Millwood). 2011 Aug;30(8):1434-42. doi: 10.1377/hlthaff.2010.1024. PMID: 21821561.

5: Rhee TG, Rosenheck RA. Initiation of new psychotropic prescriptions without a psychiatric diagnosis among US adults: Rates, correlates, and national trends from 2006 to 2015. Health Serv Res. 2019; 54: 139–148. https://doi.org/10.1111/1475-6773.13072

6:  Wong J, Motulsky A, Abrahamowicz M, Eguale T, Buckeridge DL, Tamblyn R. Off-label indications for antidepressants in primary care: descriptive study of prescriptions from an indication based electronic prescribing system. BMJ. 2017 Feb 21;356:j603. doi: 10.1136/bmj.j603. PMID: 28228380; PMCID: PMC5320934.

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10:  Hirsch M, Birnbaum RJ.  Switching antidepressant medications in adults.  UpToDate.  Accessed 7/15/2026:  https://www.uptodate.com/contents/switching-antidepressant-medications-in-adults

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16:  Gravensteen IK, Ekeberg Ø, Thiblin I, Helweg-Larsen K, Hem E, Rogde S, Tøllefsen IM. Psychoactive substances in natural and unnatural deaths in Norway and Sweden - a study on victims of suicide and accidents compared with natural deaths in psychiatric patients. BMC Psychiatry. 2019 Jan 18;19(1):33. doi: 10.1186/s12888-019-2015-9. PMID: 30658618; PMCID: PMC6339417.

17:  Chitty KM, Buckley NA, Lim J, Ali Z, Schumann JL, Cairns R, Daniels B, Pearson SA, Preen DB, Schaffer AL. Psychotropic and other medicine use at time of death by suicide: a population-level analysis of linked dispensing and forensic toxicology data. Med J Aust. 2023 Jul 17;219(2):63-69. doi: 10.5694/mja2.51985. Epub 2023 May 25. PMID: 37230472; PMCID: PMC10952140.

18:  Valuck RJ, Orton HD, Libby AM. Antidepressant discontinuation and risk of suicide attempt: a retrospective, nested case-control study. J Clin Psychiatry. 2009 Aug;70(8):1069-77. doi: 10.4088/JCP.08m04943. PMID: 19758520.

19:  Coupland C, Hill T, Morriss R, Arthur A, Moore M, Hippisley-Cox J. Antidepressant use and risk of suicide and attempted suicide or self harm in people aged 20 to 64: cohort study using a primary care database. BMJ. 2015 Feb 18;350:h517. doi: 10.1136/bmj.h517. PMID: 25693810; PMCID: PMC4353276.

20:  White A, Thornton RLJ, Greene JA. Remembering Past Lessons about Structural Racism - Recentering Black Theorists of Health and Society. N Engl J Med. 2021 Aug 26;385(9):850-855. doi: 10.1056/NEJMms2035550. PMID: 34469642

21:  McCoy J, Rahman T, Somer M. Polarization and the global crisis of democracy: Common patterns, dynamics, and pernicious consequences for democratic politics. American behavioral scientist. 2018 Jan;62(1):16-42.

22:  Mason L. Uncivil agreement: How politics became our identity. University of Chicago Press; 2022 Dec 22.

When politics is your identity merged with other identities like race, religion, local culture – the intensity toward out-group hostility intensifies because it seems like an existential threat - but - it is not.

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4:  Cortese S. Pharmacologic treatment of attention deficit–hyperactivity disorder. New England Journal of Medicine. 2020 Sep 10;383(11):1050-6.

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7:  Alegría M, Alvarez K, Cheng M, Falgas-Bague I. Recent Advances on Social Determinants of Mental Health: Looking Fast Forward. Am J Psychiatry. 2023 Jul 1;180(7):473-482. doi: 10.1176/appi.ajp.20230371. PMID: 37392038; PMCID: PMC12096341.

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15:  Dietary Guidelines for Americans, 2025-2030:  https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf

16:  Walrath-Holdridge M. RFK Jr. says keto can 'cure' schizophrenia. Can a diet alleviate mental illness?  USA Today Feb 19, 2026:  https://www.usatoday.com/story/news/health/2026/02/19/rfk-jr-keto-diet-cure-schizophrenia/88739528007/

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25:  Cutler DM. The Worst Piece of Health Care Legislation Ever. JAMA Health Forum. 2025;6(8):e254626. doi:10.1001/jamahealthforum.2025.4626

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