A Few More Lost Pieces of the Antidepressant Discussion

 

There was a lengthy article in the New York Times 2 days ago on antidepressants (1).  The main premise of the article is that millions of children and young adults were prescribed antidepressants.  The antidepressants may have been effective for the crisis but now that they continue on them, they have side effects and want to discontinue them because they feel emotionally blunted and disconnected. The chemical imbalance trope was invoked several times.  The author proceeds to extend the argument to suggest that there are millions of people in this predicament, physicians are unwilling or unable to help, and HHS Secretary Robert F Kennedy (RFK) is going to solve the problem largely by reforming psychiatry purportedly by moving into the “rift between patient and doctor” and promising to “free the mental health of Americans from dependence on pills”.

I have addressed this issue in many places on this blog.  That includes my response to RFKs arguments, RFKs comparison of SSRI withdrawal to heroin withdrawal, and strategies to prevent the problem including exposing only those people to antidepressants who need them, using medications with lower withdrawal risk, and generally being aware of the problem. I have also written about how long the problem has existed, when the first review of the problem was written, and that it is a fundamental skill that all physicians should have. 

In the RFK response I was also able to find out that the detailed antidepressant tapering and transition instructions have been in the premier online medical resource UpToDate for at least 18 years. Any practicing physician with access has those details. The facts as they exist show that RFK does not have a rational or even reasonable approach to the problem.  His idea that antidepressants are overprescribed and impossible to stop obfuscates the real problems of undertreatment and both active removal of treatment resources while promoting more high-risk treatment by the Trump administration.  In brief, the RFK approach to mental health has taken a solvable problem of not enough resources and blown it up into another problem.

To be clear, I am not commenting on the anecdote in the New York Times piece.  I have no personal knowledge of the patients or families mentioned.  I think a presentation of any similar situations in medicine should raise the questions: Why is a treatment being continued if it is not at least partially effective for the symptoms?  Why is a treatment not discontinued if the patient or family would prefer, they not take it?  What other treatments were tried before a medication was tried and what other treatments were tried concomitantly?  Invariably that all comes down to the expertise of the physician and knowing that the primary role to give the best advice to the patient and not make up their mind for them.  It is their job whether to take it or not. Almost everybody I encountered in practice had a preference to not take any medications. They either changed their mind about that after a lengthy informed consent discussion or not.  Either answer was fine with me. 

A confounding factor in any longitudinal analysis of medication effects is how people adapt to medications over time.  The first time I discontinued a maintenance antidepressant was in 1986.  That patient was a blue-collar worker who had been on doxepin for many years for migraine headaches and depression.  When I started seeing him his main problems were fatigue and hypersomnia.  I tapered and discontinued the doxepin.  He did well and eventually told me that he did not realize it at the time but he felt like he had the flu while he was on doxepin and that resolved after it was stopped.

Just as people can be unaware of long-term side effects after years on any medication – they can also get habituated to the therapeutic effects. That is the main reason people need close follow up when medications have been discontinued. Those effects go far beyond treating the primary disorder. People will report not feeling as well, not thinking as clearly, and not being as mentally flexible as when they were taking the medication.  In some cases they will experience a recurrence of a secondary disorder that was treated by the antidepressant like migraine headaches or back pain.  None of the symptoms described are due to withdrawal or a clear recurrence of the primary disorder but they would prefer to stay on the medication.

My main concern with the antidepressant controversy is that it is essentially a polarizing political argument at this point.  As far as psychiatry goes, nobody is talking about psychiatry the way I practiced it, how my colleagues practiced it, or how I trained residents to practice it.  The idea that any medication is good or evil is absurd.  The idea that the prescribers of medication are forcing it on clueless unsuspecting patients for the benefit of the pharmaceutical industry is equally absurd.  The most absurd arguments is that RFK or antipsychiatrists are going to save everyone on an antidepressant or psychiatric medication.  How will that happen when all the evidence is ignored and you have the expertise of a political podcaster?

To end this post, I want to include an important part of the antidepressant argument that I have ignored until now and that is how many people stop taking them.  There is a constant drumbeat of how many people take them and inaccurate suggestions that too many take them, so why would I think people stop taking them?  For many years, I worked for a healthcare company and I was on their Pharmacy and Therapeutics (P&T) Committee.  As such we were gatekeepers for medications that would be listed on the health plan formulary and were available to subscribers. We assessed the scientific data on efficacy but also the cost. At some point we also discussed compliance (now referred to as adherence) to the prescribed medications.  We found that a significant number of people never refilled their second prescription for antidepressants. At that point we began sending out reminder letters about the importance of adhering to the medication until there was agreement with their doctor that they should stop.

This occurred in the time frame of about 1995-2005. It was a health plan wide initiative meaning that most of the antidepressants were prescribed by primary care doctors. Stigma and the stigma of psychiatric medications was still hotly debated. There was still active misinformation about psychiatry and psychiatric medications.  There is always a personal bias to not take medications unless they are absolutely necessary. In terms of pure antidepressant prescribing I am sure that in many cases they were prescribed unnecessarily for self-limited crisis situations.  The important information here is that large number of patients stop taking these medications and that is never discussed.  It would be in opposition to the usual political argument of excessive prescribing and an inability to stop.       

What would that look like at a national and international level?  A commonly cited statistic is that 50% or persons prescribed antidepressants discontinue them in the first 6 months although many of the studies have lower estimates (see table below).  There are also several studies that estimate population wide use of antidepressants as both a percentage of the population (2-4) and absolute numbers (5).  The 2023 National Health Interview Survey found 11.4% of all adults ≥18 took antidepressant medication. The total population is 269.8M people so that is about 31M people.  Based on the available discontinuation percentages of 22 to 42.9% that means in any given year – 6.82 to 13.2 million people stop taking antidepressants.  Considering that as many as half of the antidepressants starts are for conditions other than depression it is likely that as many people are starting antidepressants as stopping them.   At least some of the survey data indicates that some of the reasons for stopping has to do with negative press and misinformation (fear of dependence)  – a known factor in the nocebo effect.

 

The above estimate is just that.  Four of the 5 studies are surveys.  There is no patient level data on a national scale that looks specifically at the antidepressant discontinuation issue.

There is data that looks at what happens at the treatment level.  That comes from a Danish register study of 66,540 older adults aged 65 or greater treated for depression who received a first-time antidepressant prescription between 2006 and 2016 (7).  Register studies are observational but they have the advantage of detailed information at the individual patient level about interventions when the databases are linked to clinical and pharmacy information for nationwide health plans. In this study, 33.7% of patient stopped antidepressants within 6 months, 26.5% gradually stopped over a period of 2 years, and 39.8% were on antidepressants for the entire 3-year period.  They studied the social determinants of this antidepressant use and also compared use to the recommended guidelines for antidepressant treatment in Denmark. Those guidelines suggest at least 6 months of maintenance treatment after initial remission and 2 years of maintenance for recurrent depression.  One of the social determinants was living in a non-urban area and the authors suggest this may be related to access to mental health specialty care.

The interesting aspect of the information in the Danish study was the detailed information across three general trajectories of antidepressant use.  Those trajectories are commonly seen in psychiatric practice and are far more realistic than what is typically portrayed in the media.  That includes the NYTimes article.       

When you read an article like that one or one of the many I have noted in the past – ask yourself what you really learned.  Like all medications antidepressants have side effects.  In fact, I routinely advised patients was that one person in six or seven would not tolerate them at all either due to initial side effects or withdrawal effects.  In clinical practice or real life - I never met a patient who told me they liked taking medications of any type.  Neither of those factors was a deterrent to trying a medication for most people.  The reason is that they were seeing me was for a severe, life changing problem and they had tried many other interventions. The Danish study (7) showed that only about 3% of that sample was ever hospitalized for severe depression.  Those were the patients I was treating.  

The psychiatric treatment of people over time is a dynamic process. It generally involves more than just medication with close attention to psychological factors and necessary lifestyle interventions. It requires a close collaborative relationship between the patient and the psychiatrist that includes a focus on optimizing therapy, minimizing or eliminating side effects and paying close attention to patient preferences. With that general approach, nobody should regret taking a medication longer than they should.  Nobody should put up with significant side effects.  And nobody should take a medication that is not working.  All of that is open for discussion.

Where I come from there is no rift between the patient and the doctor for RFK to fill.  And if there was – he is the wrong man to fill it.  

      

 George Dawson, MD, DFAPA

 

References:

 

1:  Bromley C.  A Generation on Antidepressants Searches for the Exit.  New York Times.  August 7, 2026.

2: Brody DJ, Gu Q. Antidepressant Use Among Adults: United States, 2015-2018. NCHS Data Brief. 2020 Sep;(377):1-8. PMID: 33054926.

3:  Mojtabai R, Olfson M. National trends in long-term use of antidepressant medications: results from the U.S. National Health and Nutrition Examination Survey. J Clin Psychiatry. 2014 Feb;75(2):169-77. doi: 10.4088/JCP.13m08443. PMID: 24345349.

4: Fu G, Li M, Lang X, Luo M, Chen S. Trends in depression and antidepressants use by social determinants of health among adults in the United States: Data from NHANES 2005-2018. J Affect Disord. 2026 Feb 1;394(Pt B):120662. doi: 10.1016/j.jad.2025.120662. Epub 2025 Nov 10. PMID: 41224008.

5:  Chai G, Xu J, Goyal S, et al. Trends in Incident Prescriptions for Behavioral Health Medications in the US, 2018-2022. JAMA Psychiatry. 2024;81(4):396–405. doi:10.1001/jamapsychiatry.2023.5045

6:  Elgaddal N, Weeks JD, Mykyta L. Characteristics of adults age 18 and older who took prescription medication for depression: United States, 2023. NCHS Data Brief. 2025 Apr;(528):1-9. DOI: https://dx.doi.org/10.15620/cdc/174589.

7:  Ishtiak-Ahmed, K., Rohde, C., Köhler-Forsberg, O., Christensen, K.S. and Gasse, C. (2024), Depression Treatment Trajectories and Associated Social Determinants: A Three-Year Follow-Up Study in 66,540 Older Adults Undergoing First-Time Depression Treatment in Denmark. Int J Geriatr Psychiatry, 39: e70006. https://doi.org/10.1002/gps.70006.

 

Supplementary 1: The decision about medications is common in any country with the availability of advanced therapeutics.  I personally take three medications every day that I would prefer not to take. I have to self-monitor for side effects including blood pressure readings every day.  If a doctor tries to give me a temporary antibiotic prescription – I personally do a drug interaction check and let them know if that medication is compatible.  I decide to take the medication not because it makes me feel better every day but because I know the cumulative effects of not taking it are potentially very bad and therefore, I decide to take it.  I have experienced side effects and complications that I had to figure out myself and that doctors missed.  This is all part of what it means to take a prescription medication. 

All of the steps I take to protect myself are the same steps I took with any medication I prescribed for patients.