Yves here. The fact that antidepressants loom so large in our collective discourse says that there is something wrong with society. That is not to say that a lot of people do not benefit from them. But even before how people are being treated, look at some raw figures from Statista:
These results are significantly due to a society that has no interest in what it takes to create emotionally satisfied lives. Neoliberalism demands that community and personal relationship be subordinated to job needs. Relentless advertising and status competition reinforce the message that happiness lies in having better stuff and staying on the sugar high of gratification-by-shopping. And many if not most are also very poorly trained in coping skills, like an acceptance of failure and losses. The purpose of the world’s major religions is to help followers deal with the inevitability of suffering and death.
One of the reasons of the broad use of antidepressant is not just the hope of a quick fix, but the need for one in which for nearly all, selling your labor is a condition for survival, and thus one cannot afford the productivity drag of depression and grief.
Johann Hari is a forceful advocate of this line of thinking. One can contend that he’s too doctrinaire, but it is hard to deny that he is on to something. From a 2018 post:
Below we’ve posted an interview with Hari on his new book, Lost Connections, which is an investigation of the depression industry, although he doesn’t call it that. His work started with his own experience, of being medicated for depression starting as a teenager and only having at best short-term relief. He found it striking that his experience of rising doses with what amounted to relapses was common and was also taking place when the number of people taking anti-depressants and other psychoactive medications was exploding.
As you will see, Hari makes a strong-form argument that the causes of the big increase in reported cases of depression are social, that the modern work environment is particularly hostile to people having a sense of control and purpose that is important to well being. He also contends that the “brain chemistry imbalance” theory of depression was not proven when selective serotonin uptake inhibitors like Prozac were becoming popular and even as of today does not have a solid scientific foundation.
Another angle Hari discusses is the way that advertising induces people to make unhealthy social choices. I wont’t give away the anecdote in his video. But more broadly, advertising is designed to create needs and wants, which means preying on insecurities and desires. Moreover, a great deal of advertising presents people who are “happy” as the result of consuming the product or service on offer. That happiness is seldom contentment or relaxation; instead it is usually giddy or euphoric. Those aren’t sustainable states. They are brief highs. But the message to consumers on a large scale basis is that that is what your life should look like, and if it doesn’t, you must be doing something wrong…
Some medical professionals have objected strenuously to Hari’s book. They content that he’s incorrect in depicting anti-depressants as generally not beneficial and claiming that psychiatrists don’t give much/any weight to life experiences when prescribing anti-depressants.
The wee problem is that there is a big gap between the theory of how psychiatry ought to be done and what is actually taking place. My large sample (relatives who’ve suffered from depression, and way too many people I know personally who are taking anti-depressants) is that at least in the US, the pattern conforms to what Hari describes: doctors, including GPs, all too eager to hand out drugs like Prozac and Adderal, with no psychological evaluation whatsoever. From what I can tell, in major US cities, they are seen as productivity enhancers and thus perfectly fine to prescribe casually.
By contrast, one of my former lawyers who is also a biomedical engineer is FDA specialist, and many of the partners in her boutique intellectual property firm are former FDA commissioners with serious medical and/or science backgrounds. She has mentioned repeatedly that while they take Valium casually, to a person they’ve made clear that they would never take an SSRI and have advised her to steer people away from them. So it isn’t just members of the great unwashed public who have reservations.
As Hari points out in an excerpt from his book, one of the problems with talking about SSRIs is that the drug companies have been cherry-picking studies for decades. Not only is the efficacy of SSRIs not so hot (around 50%), it’s not much higher than the placebo rate (30%).
The focus of this article is a new JAMA study on anti-depressant withdrawal, finding that it was typically no biggie. But that study has been savaged by critics. It included only short-term users, for eight to twelve weeks, when other studies have found a strong correlation between the duration of usage and the severity of withdrawal issues.
So this article is good as far as it goes and does raise important issues about how the success or failure of antidepressants is often improperly framed, in a way that too often can make the patient feel hopelessly broken. But IMHO it does not go far enough.
By Dr. Eric Reinhart, a psychiatrist, political anthropologist, and psychoanalytic clinician. He works with individuals and collectives around the world. Originally published at Undark
A recent study in the journal JAMA Psychiatry claims to offer reassuring news to hundreds of millions of people who are taking, or considering taking, antidepressants: Withdrawal from the medications, it said, is usually mild and below the threshold for clinical significance. The analysis, which drew on data from more than 17,000 patients, was quickly picked up by international news outlets. Critics responded just as quickly, calling it misleading and dismissive of real-world suffering.
As both a practicing psychiatrist and critic of the harms inadvertently inflicted by my own field, I fear we’re having the wrong debate — again.
Every few years, another study or media exposé reignites controversy over these drugs: How effective are they really? Are withdrawal symptoms real or imagined? Are antidepressants harming people more than they help? These questions, while important, are stuck inside the narrow terms set by a medication-centric psychiatric industry, even when criticizing it. They flatten the experience of patients and ignore the intersecting role of clinicians, families, institutions, media, culture, and public policy in shaping both suffering and relief, trapping us in circular debates and deflecting attention from other ways of understanding and addressing what ails us.
Yes, antidepressant withdrawal is real. Yes, some people suffer greatly while trying to come off these drugs, with withdrawal risk varying among different kinds of antidepressants. I have also seen many patients appear to benefit greatly from such medications. But when we focus only on the biology of response and withdrawal, or treat psychiatric medications as purely pharmacologic agents whose harms and benefits can be definitively measured and settled by clinical trials, we obscure the more complex — and far more consequential — dynamics by which these medications affect self-perception, social relationships, and political life.
Although antidepressants have an appropriate place in psychiatric treatment, they’re frequently prescribed in caseswhere they are unlikely to do much good. The risk of harm commonly outweighs likely benefits, especially under the norms of highly time-constrained, decontextualized, and impersonal clinical practice today, in which medications are often prescribed at the very first appointment. And while I am a critic of the overprescription of antidepressants, I am also wary of the growing public discourse that treats them and psychiatry itself as the primary cause of ongoing pain.
In some cases, what gets labeled as withdrawal is not a straightforward physiological reaction to discontinuing a chemical agent. It can be a complex response to the loss of an object that was invested — often by one’s doctor, one’s family, dominant cultural ideas, and patients themselves — with enormous psychic and symbolic significance. If a pill is presented as a cure for debilitating anxiety tied to grief or trauma, for example, or accepted by a patient as a last-ditch attempt to stave off despair and self-harm, its failure to deliver relief can be devastating and worsen the distress that led to starting the medication.
Symptoms after stopping medications can also represent the return — whether in new or old forms — of underlying suffering that was never addressed. This often happens in part because treatment has primarily revolved around generic symptom checklists and decisions on what medications to use rather than meaningful engagement to understand a patient’s experience in the context of their unique life history, needs, conflicts, and desires.
This isn’t a claim that withdrawal symptoms are “all in your head.” It’s a repetition of the well-known but widely disregarded reality that mind and body are not separate, and neither are biology and culture. Symptoms emerge in particular social contexts and take shape through the meanings we attach, typically without our awareness, to them. This is how, for example, what was once considered ordinary sadness or grief has been transformed into a symptom of depression, or how experiences of fatigue or loss of interest that might come from overwork or boredom have been recast as mood and attention disorders.
How we name our experiences and how people around us respond to them affects, in turn, how we feel and navigate them. This culturally contingent nature of symptoms also holds true for the experiences of taking and stopping medications like antidepressants, and it’s true for the conditions they’re meant to treat.
Psychiatry, since the 1970s, has fostered a widespread misrecognition of psychic suffering as the product of discrete brain disorders. This medicalizing narrative has encouraged people to understand their experiences of distress as, first of all, a biological problem to be chemically treated. And when the chemical fix fails, which psychiatry’s own data show it often does, patients are left not only with their original problems but also with a sense of betrayal and confusion. Some come to attribute their suffering to psychiatrists and medications themselves. In some cases, that attribution is almost certainly correct; there are reckless doctors and serious medication side effects. But it’s rarely so simple.
This misrecognition often reflects a deeper one that psychiatry has long cultivated: a tendency to conflate complex social and psychic distress with biological dysfunction. It then fuels what medical science calls the nocebo effect — a negative placebo response — whereby suffering becomes attached to and caused by the idea of a drug, even when the chemical effects of the drug are not in fact the direct cause of one’s symptoms. The nocebo effect, in this case, is not incidental, nor does it mean that psychiatry is not responsible for it. It is an unintended consequence of the very narratives that psychiatry has used to justify its authority and economic value.
Psychiatry has offered simplistic diagnostic labels as if they, by themselves, provide adequate explanations. The result is a vicious cycle: A culture prescribes pills in response to psychic pain, then blames those pills for pain when it persists.
Myriad unintended consequences ensue. People can become locked into an identity as patients defined by biological defectiveness. And even if some patients later reject psychiatry entirely and turn away from psychiatric treatments, many remain captive to them by fixating on those treatments as the source of their problems. Many people invest enormous time, money, and energy into peer forums, withdrawal support communities, and alternative wellness treatments that, while offering a crucial sense of community, can also risk reinforcing the very captivity they seek to escape. These alternatives promote a fixation on the body as a malfunctioning machine, now recast not as chemically deficient but as chemically damaged. In both frames, suffering is narrowly viewed through biology, rather than through the layered histories and defining contradictions of each individual’s singular experiences acting in conjunction with their effects on the body.
Side effects or withdrawal symptoms aren’t the most pernicious harms inflicted by contemporary psychiatry and its medications. Rather, they lie in the failure — of both the clinic and the popular public discourse that has been shaped by psychiatric ideas and language — to facilitate the development of nuanced, individually contextualized, and practically useful frameworks for patients to make sense of social suffering. That failure leaves people vulnerable to simplistic pseudo-solutions: Take another pill, or never take a pill again.
It also feeds into misguided and misleading rejection of medical science and psychiatric care by opportunistic figures like Robert F. Kennedy Jr. and the aligned, profit-driven “Make America Healthy Again,” or MAHA, wellness industry. Kennedy has suggested that antidepressants fuel school shootings and has called for a government investigation into the “threat” to society posed by psychiatric medication. He and his allies in President Donald Trump’s administration take advantage of popular culture’s lack of understanding of social experience and mental health to promote moralistic, racist, punitive, and ultimately eugenicist ideologies. With these, they then dismiss suffering and mental illness among poor, disabled, and minority groups as an individual’s own fault, suggesting that they should be ostracized and punished rather than provided support and care.
This narrative, in turn, supports attempts to justify cutting essential public welfare and medical programs while reallocating their funds into expanding systems for policing, incarceration, and deportation. The strategy is encapsulated in Trump’s recent executive order aimed at reopening mental institutions by using police to arrest and then, apparently without any due process, indefinitely forcibly institutionalize poor Americans who are unhoused, judged to be mentally ill, or struggling with addiction.
To stop these cycles of harm, what we need is not yet more superficial debates about medications but a reckoning with the policies and associated ideas that generate and perpetuate distress that drives demand for pharmacologic balm. Mental health professionals should help people — and culture writ large — to identify the psychosocial, historical, and political roots of what they are experiencing and how their suffering could be modifiable through social action at both individual and collective scales. That means reversing the overmedicalization of mental health and illness in order to confront the political determinants of health: poverty, racism, social isolation, inequality, mass incarceration, and growing levels of political violence and nihilism amid the rise of oligarchy. It means reinvesting in public systems of care and rebuilding them on a new community-oriented basis that offers time, attention, and sustained relationships, rather than just doctor’s appointments, diagnostic codes, and 15-minute medication checks.
It requires psychiatrists to ensure that people have the space and time to tell (and retell) their stories on their own terms — not by simply describing their symptoms, being assigned a psychiatric diagnosis, or completing six sessions of formulaic cognitive behavioral therapy, but by sharing their personal histories, desires, losses, and dreams. And it also requires providing people everyday opportunities to care for one another, which is an essential role for feeling and affirming one’s own social value, rather than defaulting to the presumption that only licensed medical professionals are capable of providing meaningful care to people experiencing distress.
To achieve this, we need to invest in more and better care, not less. And to make that happen, we need to rally as a political community to demand policies that support this goal rather than allow the Trump administration to continue decimating the nation’s already deficient public health and welfare infrastructures in service of further privatization and profits.
This must be the crux of any real plan to accurately diagnose and effectively address the causes of declining mental health in America. It is what we must insist upon at every turn. And it is only when we do so that the uses and limits of medications like antidepressants are likely to finally be put right.
