Antidepressants are back in the spotlight, and the debate around them is louder than ever. Robert F. Kennedy Jr., in his role overseeing the U.S. Department of Health and Human Services, recently announced a campaign to reduce prescriptions for these widely used medications. The push, which HHS framed as an effort to curb what it described as psychiatric overprescribing, calls on doctors to first encourage patients to try lifestyle changes such as diet and exercise before reaching for a prescription pad.
He stopped short of an outright ban, making clear that no one currently on an antidepressant would lose access to their medication. Still, the announcement lit up social media and comment sections with a mix of relief and alarm a reaction that reflects just how deeply personal these medications can be for millions of Americans.
Antidepressants have been in use for roughly 70 years. Tens of millions of Americans currently take them. And yet they remain widely misunderstood. Two psychiatrists help answer the most pressing questions.
What exactly are antidepressants?
The term antidepressant covers a broad category of medications used not only for depression, but also for anxiety, obsessive compulsive disorder and eating disorders. There are approximately 30 drugs approved by the Food and Drug Administration in this class, and they vary widely in form, dosage schedule and side effect profile.
The most commonly prescribed are selective serotonin reuptake inhibitors, or SSRIs the group Kennedy has specifically targeted. These include widely recognized medications such as Zoloft, Lexapro and Prozac. SSRIs work by helping the brain retain more serotonin, a neurotransmitter linked to mood regulation. Research has consistently shown they improve symptoms in many though not all patients. Exactly how they work, however, remains an open question. Their use has long been based on the theory that low serotonin causes depression, but scientists now believe the condition is far more complex than that single explanation suggests.
Are they overprescribed?
The honest answer is: probably both over and under prescribed, depending on the patient. Estimates suggest that between 12% and nearly 17% of Americans currently take antidepressants. A 2015 study estimated that roughly one in five prescriptions was unnecessary. A separate study of older adults found that the majority of those 65 and older on antidepressants didn’t meet the clinical criteria for major depressive disorder.
At the same time, that same 2015 study found that Black and Asian Americans who did meet the diagnostic criteria were prescribed antidepressants at roughly half the rate of white Americans. Many people also never seek help in the first place because they don’t recognize what they’re experiencing as a mental health condition. Stigma around psychiatric treatment remains a significant barrier, with many patients reluctant to accept that they need medication even after arriving at a psychiatrist’s office.
Can diet and exercise really treat depression?
Yes — in some cases. Both psychiatrists interviewed for this article say they regularly see patients for whom lifestyle changes are the appropriate first step, and they were trained to recommend those interventions before prescribing medication. Exercise is included in American College of Physicians guidelines for major depressive disorder, and some research suggests it may work nearly as well as medication in certain patients.
The complication is that depression itself often makes those interventions extremely difficult to follow. Reduced motivation is one of the disorder’s defining symptoms. Psychiatrists note that patients who walk into their offices are frequently people who have already tried healthier routines, therapy or both before arriving. For those who cannot benefit sufficiently from behavioral changes, medications often provide the stability needed to then build those habits.
Do people have to stay on antidepressants forever?
In most cases, no. Antidepressants generally take four to eight weeks to begin working, and most people take them for six months to a year. Once a patient is doing well, the question of whether to continue or slowly taper off is typically revisited together with their doctor.
Age plays a role in that decision. Younger brains are still developing and more neurologically flexible, which means a shorter course of treatment can sometimes set the brain on a lasting, healthier path. Older adults have less of that flexibility and may need longer term use. Either way, a prescription is not necessarily a lifelong commitment some people stop and stay off, others return to medication later, and still others choose to remain on it long-term.
What about side effects?
The most common side effects include nausea, headache, weight gain, sexual dysfunction, insomnia or excess sleepiness and dry mouth. One study found that 38% of people on antidepressants experienced at least one side effect, though only a quarter described those effects as very or extremely bothersome. Research suggests that up to 80% of people on SSRIs report some degree of sexual problems a concern Kennedy has highlighted though it’s worth noting that between 35% and 50% of people with untreated major depression also report sexual dysfunction, according to Harvard Health.
Are antidepressants addictive?
No. Kennedy drew a comparison between stopping antidepressants and opioid withdrawal, but psychiatrists strongly dispute that framing. Addiction involves cravings, compulsive drug-seeking behavior and loss of control none of which are associated with antidepressant use. These medications do not act on the brain’s reward pathways the way addictive substances do.
What can occur is physical dependence, meaning the body adapts to the drug and may react when it is stopped abruptly. Known as antidepressant discontinuation syndrome, this can cause nausea, insomnia, fatigue, irritability and a sensation patients often describe as brain zaps. About 15% of people coming off antidepressants experience withdrawal symptoms, and roughly 3% have severe ones. Tapering the dose gradually over several months, rather than stopping suddenly, significantly reduces those risks.
Both psychiatrists acknowledge there is some validity to concerns about overprescribing. But they caution that the risks of undertreating depression are serious and, for some patients, life-threatening. For many people, these medications have made it possible to hold jobs, maintain relationships and, in some cases, stay alive.
