Anti-depressant drugs are widely used in many countries as a treatment to alleviate the problems psychiatry labels as 'depression'. People acquiring this diagnostic label will typically be experiencing intense suffering in the form of enduring low mood and/or a loss of interest and enjoyment from day-to-day activities. In addition, some of the following signs will also be present: sleep disturbance, loss or increase in appetite, weight loss or weight gain, suicidal ideas, loss of energy, strong feelings of worthlessness or guilt, restlessness, poor concentration and indecisiveness.
Before taking anti-depressants it is important to be aware of the following pieces of information, some of which might not always be shared by the prescribing doctor.
1. Anti-depressants are of different types
If you are unfortunate enough to suffer 'depression', the treatment most likely to be offered is anti-depressant drugs. First developed in the 1950s, there are now several different types which differ on the basis of their chemical structure and how they work. The three most common groups of anti-depressant drugs currently prescribed are the Tricyclics, Selective Serotonin Re-uptake Inhibitors (SSRIs for short) and the Serotonin and Nor-adrenaline Re-uptake inhibitors (SNRIs for short). The drug companies, together with most psychiatrists, often claimed that these drugs work by increasing chemicals in the brain that affect our mood, namely nor-adrenaline (nor-epinephrine) and serotonin. However, there is little evidence for this mode of action.
Specific examples of these three popular groups of anti-depressant drugs, with brand names in brackets, are given in the table.
Amitriptyline (Triptizol, Elavil)
Citalopram (Cipramil, Celexa)
Fluoxetine (Prozac, Fontex)
Duloxetine (Cymbalta, Yentreve)
Paroxetine (Seroxat, Paxil)
Doxepin (Sinaquan, Adapin)
Sertraline (Lustril, Zoloft)
Imipramine (Tofranil, Janimine)
Lofepramine (Gamanil, Lomont)
2. Anti-depressants are less effective than often claimed
Drug company advertisements, along with doctors and psychiatrists, often claim that anti-depressant drugs are of great benefit to the majority of people who suffer 'depression'. Indeed, in the United Kingdom the Royal College of Psychiatrists state on their website that, based on the relevant research, it is reasonable to conclude that between half and two-thirds of patients will be ‘much improved’ after three months of treatment.
However, a thorough inspection of the data leads to a radically different conclusion. When Irving Kirsch (a Professor of Psychology) and his colleagues (Kirsch et al., 2008) conducted a comprehensive review of the evidence, including both published and unpublished studies, their conclusion was that the SSRIs were only effective in a very small number of the most depressed patients; for the great majority of people these modern, state of the art anti-depressants had therapeutic effects that were no better than that of a placebo (that is, the benefit people obtain from taking a pill that they believe will help when, in reality, they are taking an inert substance containing non of the active ingredient). Importantly, in severely depressed patients, the superiority of the anti-depressant may have been due to this group being less susceptible to the placebo (rather than to any enhanced responsiveness to the drugs).
A recent review - published in February 2017 - casts even more doubt on the effectiveness of SSRIs. After combining the findings of many previous research studies exploring the helpfulness of this type of antidepressant, the authors concluded that their 'clinical significance seems questionable' - in other words, although these drugs might achieve a some small improvement in scores on a research questionnaire, the actual benefit for people's lives overall may be inconsequential. Furthermore, consideration of the side-effects and adverse reactions associated with these drugs led the authors to state that 'the potential small beneficial effects seem to be outweighed by harmful effects'.
3. Anti-depressants are over-prescribed
Between 1995 and 2004 the number of anti-depressant prescriptions issued in the USA tripled so that, by 2005, 10% of the population (27 million people) were taking them. Similarly, 10% of middle aged adults across Europe had taken anti-depressants in 2010. Such remarkably high figures suggest that these drugs are too freely dispensed to patients, particularly when one considers that there are a range of alternative interventions (for example talking therapies or exercise) that are, in general, at least equally as effective. More worryingly, this increased prescribing of anti-depressants is not restricted to adults. In 2007 almost 110,000 children in the United Kingdom were taking these drugs, a 40% increase on the 1997 figure.
4. Anti-depressants cause unwanted side effects
All medications have side effects and anti-depressants commonly produce a range of unwanted consequences. Tricyclics are associated with dry mouth, hand tremor, racing heart, constipation, weight gain, drowsiness, low blood pressure, erectile problems and delayed ejaculation. SSRIs can cause increased anxiety, nausea, indigestion, aggression, agitation and sexual dysfunction. Although most of these side-effects disappear within a few weeks, they are unwelcome irritants for people who are already suffering.
5.Anti-depressants may cause an increase in suicidal feelings
A much more serious side effect has been occasionally reported, regarding young people experiencing an increase in suicidal feelings after taking SSRIs, an adverse reaction that led to a ban on the prescription of SSRIs to people under 18 years of age.
A recent (2012) study looking at the data obtained from 9000 young people did not find that Fluoxetine (a commonly prescribed SSRI) increased suicidal thoughts. It is also worthy of note, however, that neither did this study provide any evidence that this popular anti-depressant decreased such thoughts.
The evidence on this issue remains conflicting.
6. Trycyclic anti-depressants are dangerous in overdose
A drawback with the older, tricyclic anti-depressants is their high level of toxicity that renders them potentially lethal in overdose – a major concern for a drug prescribed for depressed people, where suicide risk is a common concern. The SSRIs are much less dangerous in overdose.
7. Anti-depressants do not rectify chemical imbalances in the brain
Contrary to the claims of the pharmaceutical industry and many psychiatrists, there is no consistent evidence that anti-depressants achieve their benefits via specific increases in the levels of nor-adrenaline and serotonin. It is likely that these drugs affect numerous other neuro-transmitters in the brain.
Many anti-depressants produce a sedating effect and this is often the first thing that recipients notice upon commencing the drug. In keeping with other psychoactive drugs, anti-depressants are likely to reduce a person’s sensitivity to their environment. Given that depressed people often suffer with insomnia and agitation, the arousal reduction may be the most helpful consequence of the drug – the finding that other sedative drugs (benzodiazepines, anti-psychotics, opiates) can achieve an equivalent anti-depressant effect lends further support to this possibility.
Further information regarding the likely effects of anti-depressants on the brain can be obtained from the excellent book by Moncrieff (2009).
8. Anti-depressants are often prescribed for problems other than depression
Anti-depressant drugs are also prescribed to people suffering from other mental health problems, not just 'depression'. These include 'post traumatic stress disorder', 'anxiety disorders' (panic, obsessive-compulsive), chronic pain and 'eating disorders'. The general sedative effects of anti-depressants (see section 7) may account for these reported improvements.
9. Many patients experience withdrawal symptoms once they stop taking anti-depressants
Although not addictive in the same sense as some other drugs such as diazepam (that produce cravings and require an increasing dose to achieve the same effect), anti-depressants are associated with a range of withdrawal symptoms, particularly if a person has been taking the medication for a long time. Up to one third of people suffer a withdrawal syndrome that can include: stomach upsets, flu-like symptoms, anxiety, dizziness, insomnia, irritability, nightmares, weepiness and feelings of electric shocks in the body. These withdrawals can last for many months.
Psychiatrists may often misinterpret some of these symptoms as “a return of the illness” and recommend re-starting the anti-depressants. To minimise the chances of experiencing withdrawals, it is advisable to taper off the dose of anti-depressant rather than stopping abruptly.
10. Most episodes of depression will improve without any treatment
Most people with depression will recover spontaneously within eight months without anti-depressants or any other form of treatment.
11. Doctors recommend that patients should continue taking anti-depressants beyond the point at which they feel better
Medical practitioners discourage patients from stopping the anti-depressant drug when they feel better and recommend that it is taken for at least six months. If the patient has suffered two or more episodes of depression, the doctor will advise taking the anti-depressants for a minimum of two years. Such recommendations are difficult to square with both the drug’s modest effectiveness and the likelihood of spontaneous improvement in depressive symptoms.
12. The myth that there is a type of depression that will only respond to anti-depressants
Psychiatrists often assert that there is a type of 'depression' that has a primary biological cause and therefore can only be remedied by a biological treatment like anti-depressant drugs. They refer to these types as a 'biological depression' or a 'depressive illness'. The research evidence does not support this assertion. Some depressed people respond well to anti-depressants, whereas some respond well to psychological treatments, but there is no reliable way of determining beforehand a type of depression that is immune to non-biological treatments.
References & further reading
Kirsch, I., Deacon, B.J., Huedo-Medina, Scoboria, A., Moore, T.J. and Johnson, B.T. (2008). Initial severity and anti-depressant benefits: A meta-analysis of data submitted to the Food & Drug Administration. PLoS Med 5(2) e45. do:10.1371/journal. Pmed.0050045.
Moncrieff, J. (2009). A Straight Talking Introduction to Psychiatric Drugs. PCCS Books. Ross-on-Wye.
Dr. Gary L. Sidley (author) from Lancashire, England on December 05, 2013:
Thanks for your support and interest, Angie.
I hope Prestcott House is ticking over nicely under your expert guidance.
Angie smith on December 05, 2013:
Another interesting read and so much easier than having to trawl through endless papers to summarise overwhelming evidence that the drugs don't work
SaritaJBonita on January 22, 2013:
I have not heard of that book and I'll have to read it. Thanks for the info
Dr. Gary L. Sidley (author) from Lancashire, England on January 22, 2013:
Thank you, Sarita, for your time and interest in this topic.
With regards to your comments:
Most mental health professionals (psychiatrists included) would accept that depression is, in most cases, a self-limiting condition that will in time right itself without treatment (medication or therapy). This was established many years ago; for example Dean Schuyler (head of the depression section at the National Institute for Mental Health) in summarizing the research evidence in 1974 stated that most depressive episodes “will run their course and terminate with virtually complete recovery without specific intervention.” Further references are provided in the book, Mad in America by Robert Whitaker (2002), who also discusses evidence that anti-depressants, although in some cases shortening depressive episodes, might actually make future relapse more likely.
Over recent decades it has been very difficult to carry out research on the natural course of depression as almost all depression-sufferers will be involved in some form of treatment. I’m certainly not advocating that people just “wait it out” – treatments may shorten the duration and/or severity of the depressive episode. Nor am I suggesting that it will “magically disappear” with therapy. What I challenge is the common assertion that the ONLY cure for so-called “depressive illness” is medication (in the same way that insulin is required to cure diabetes).
Thanks again for your interest.
SaritaJBonita on January 22, 2013:
gsidley, I would be very interested to see your research on Depression as a self-limiting illness. In my experience, Depression doesn't just magically disappear with therapy alone, if it truly is a Clinical Depression. I tried this approach once, after two years of trial and error with several different medications. I was in therapy but still extremely depressed, and I ended up trying to commit suicide. I'm not saying that this happens to most, or even some, people, but I think advocating for people to just "wait it out" is a dangerous concept.
Nevertheless, I'm always interested in research and reading, and would love to see some resources to support your hypothesis. Other than the fact that I disagree with some of your points, I think your Hub is interesting and well-written.
Dr. Gary L. Sidley (author) from Lancashire, England on October 28, 2012:
I appreciate you taking the time to comment, Sparkster, and I'm pleased you found it of interest.
I will drop by your hubs again some time soon.
Marc Hubs from United Kingdom on October 28, 2012:
This really is a very informative and well written hub. It compliments my hub on 'overcoming depression without medication' nicely!
Dr. Gary L. Sidley (author) from Lancashire, England on October 19, 2012:
Hi again Nicola. I really do appreciate your interest.
I recall many years ago (the early 1990s I think) asking a drug representative who had done a lunch-time presentation to our multi-disciplinary community mental health team (showing data about how miraculously effective his latest anti-depressant was) about data on re-bound depression when the drug was withdrawn. Surprise, surprise he didn't have any data on this!
I can go with the pair of crutches analogy to some extent, but maybe the anti-depressants are crutches that jump up and damage your legs again when you try to discard them?
Nicola Tweedie from East Sussex, United Kingdom on October 19, 2012:
Information like this is so helpful. When any of us are feeling desperate and in pain, we want a quick solution. Often with depression there isn't a quick solution, but many people I have worked with have said that they felt that taking antidepressants actually made their recovery longer. Sometimes they are helpful and really can boost a person, but like a cast or pair of crutches, they have to come away in the end, and that process takes time and lots of energy.
Dr. Gary L. Sidley (author) from Lancashire, England on September 29, 2012:
Hi zionsphere, I appreciate your interest and positive comments. It's always uplifting to connect with someone with similar interests and opinions.
My sense is that overcoming many mental health problems is typically dependent on higher level themes such as finding a purpose, engagement in meaningful activity, or development of mutually respectful relationships with other human beings.
I will drop into your hubs sometime soon.
zionsphere from Oregon on September 28, 2012:
According to my research, (And I have researched extensively over the past 6 years) medication is only effective (in most cases) with conjunctive therapies such as cognitive therapy, and relaxation techniques. I have also been doing research on the idea that many mental health issues are caused by a learning disability in the realm of coping, and problem solving skills, rather than a chemical imbalance. Thank you for touch in this subject.
Dr. Gary L. Sidley (author) from Lancashire, England on August 01, 2012:
Thanks for taking the time to drop by and your generous comments.
Kimberly Shelden from Idaho on July 31, 2012:
Well written, great information. I enjoyed the tone and context. Well done! Kimberly
Dr. Gary L. Sidley (author) from Lancashire, England on June 04, 2012:
I very much value your astute and considered comments, Kim.
I am in agreement that anti-depressants are effective for a lot of people, and I am not proposing that medication does not have a role. Where I have issues is with regards to biological/brain disturbance being purported to be the primary cause of much depression and thereby being immune from any non-chemical intervention (a view widely propagated by western psychiatric services and the pharmaceutical industry).
As for ECT, although there is some limited evidence for its effectiveness, the benefits are short-lived. Taking this alongside the associated memory loss, and the undignified/disempowering treatment procedure, I believe it is difficult to justify its use other than on rare occasions.
Kim Harris on June 03, 2012:
Hi gsidley. I like the conversational tone of this hub as well as the information in it. It is good to know that depressive symptoms will pass in time; that there is light at the end of the tunnel. That's a message of hope for a person in a depressive episode. Six to eight months is a long time though and a recurrence every few years would be difficult to weather if the symptoms are severe. Perhaps it is mild depression that is over medicated, and there may be some benefit to listening to mild depression vs. medicating it away. Too many people with severe depression avoid treatments that are available and would benefit a great deal from symptom relief through some combination of medication, ECT, exercise, social support and talk therapy. To suffer with depression for years without making any effort to recover is unnecessary suffering in my mind. This hub points out the importance of considering both the benefits and the costs of taking any medication, especially antidepressants. In some situations the benefits may far outweigh the side effects. In other situations the benefits would not justify the risks. Very thought provoking. Thanks gsidley.
Lori Colbo from United States on May 23, 2012:
Thanks for your response. I am not a doctor or pharmacist, but I have years of personal research and experience with psychotropic medications and I stand by my point on giving a medication six months. I will look forward to hearing from you soon. Thanks.
Dr. Gary L. Sidley (author) from Lancashire, England on May 23, 2012:
I appreciate your comments, lambservant, so thank you for dropping by.
In response to your challenges to points 8 and 9:
It is well established that the majority of depressive episodes will improve spontaneously without treatment within 6 to 8 months. Like the common cold, depression is typically a self-limiting condition (if interested, I will root out some references and forward them to you).
I think your comparison with antibiotics is a misleading one. Unlike respiratory infections where a clear biological cause (a strain of bacteria) has been well established, no primary biological cause has been established for depression. This is not to say that anti-depressants are ineffective (they clearly help some people). But, to use an analogy of my own, just because taking paracetamol may improve my headache this does not prove that my headache was originally caused by paracetamol deficiency.
Lori Colbo from United States on May 22, 2012:
I agree with all of your facts except that#8 and 9 are kind of iffy. To say "most" I would say requires a little documentation or research information. However, I do believe that many can recover without medication. As for stopping medication as soon as you feel better, that is very questionable. It's like people who take antibiotics for and upper respritatory infection and they feel better in a couple of days and quit taking it and get sick all over again, also risking greater resistance to the antibiotic.
I think waiting six months is more than reasonable. It takes four to six weeks just to begin working. Another few weeks to get the full effect. If you begin to feel better, then stop, your brain chemistry takes a nose dive. Then you get back on it, you risk the medication not working as effectively. And of course, like you said, a person should be weaned. The withdrawals are awful. This was a good hub though. A lot of information here that people may not know.
Dr. Gary L. Sidley (author) from Lancashire, England on February 05, 2012:
Thanks for your generous comments, Magdelene.
I was unaware of the implications for life insurance of being on anti-depressants -I will explore whether this is the same here in the United Kingdom.
Magdelene from Okotoks on February 05, 2012:
Let's talk about #7 on your list - the withdrawal symptoms once a person stops taking anti-depressants. I know a person that was on them and he had to be monitored closely by a Doctor and gradually weaned from them. To top all of that off, your life insurers look negatively upon the fact that you have ever taken any form of anti-depressants; sometimes not covering you for certain areas in your life insurance policy.
As to #9, yep, the Doctor wanted him to stay on them, told him he should not stop.
Excellent and informative Hub, points out a lot of the facts on anti-depressants. Voted up.