Are Antidepressants The Wrong Answer For Depression?

Friendship May Be the Missing Piece

Here’s a radical thought: antidepressants are addictive substances, and people get hooked on them just as they get hooked on opioids or nicotine.

Except it’s not a radical thought. It is a blunt way of looking at the evidence surrounding antidepressant use and the difficulties that arise in discontinuing that use, which recent studies make clear.

However, about half of people taking antidepressants have been using them for longer than 12 months. People can experience unpleasant withdrawal symptoms when they attempt to stop antidepressants, which leads to them restarting or continuing antidepressants.

According to a recent study¹ published in The Lancet, as many as one in six people experience severe withdrawal symptoms when they attempt to discontinue antidepressant usage. We should note that the study itself acknowledges that people often refer to the symptoms experienced when discontinuing antidepressants as “withdrawal”, even as researchers shy away from that language (for reasons which are intuitively obvious).

Experiences occurring after antidepressant discontinuation have been called withdrawal symptoms, phenomena, or events, or antidepressant discontinuation symptoms, syndromes, or symptomatology.

Moreover, the study confirmed that a third of people who discontinue antidepressants experience at least some withdrawal symptoms.

While the psychiatric community might blanche at the use of the language of addiction with respect to antidepressants, the study itself stands as a confirmation that the human body does become acclimated and even physiologically dependent upon antidepressant medication when taken for a long period of time.

Our study yielded four main results. First, across all studies and antidepressants, we found that approximately every third patient discontinuing antidepressants will have antidepressant discontinuation symptoms of any kind (event rate 0·31). Second, even in studies of people receiving a placebo, discontinuation symptoms (which could be called discontinuation-like symptoms) occurred in approximately one in six patients (event rate 0·17). Third, severe discontinuation symptoms occurred in around one in 30 patients discontinuing antidepressants (event rate 0·03). Fourth, the incidence of antidepressant discontinuation symptoms is modified by specific antidepressants, the use of instruments for detecting antidepressant discontinuation symptoms, and by study rigour, but substantial statistical heterogeneity remains.

That symptoms occur even in patients being given a placebo rather than the actual medication before discontinuing said “treatment” suggests that there is a psychological dimension to the phenomenon as well.

Small wonder antidepressants become a lifelong commitment: at least some portion of the patient population is arguably addicted (or at least physiologically dependent on them).

While doctors insist that antidepressants are an effective treatment for depression, the reality that antidepressant therapy is easier to start than to stop is a great unresolved issue within psychiatric medicine.

The researchers emphasize that there is strong evidence supporting the effectiveness of antidepressants for many individuals with depressive disorders, either alone or in combination with other treatments like psychotherapy.

However, these medications do not work for everyone and can cause unpleasant side effects for some patients.

For those who have recovered with the aid of antidepressants, doctors and patients may decide to discontinue their use over time. Therefore, it is important for both doctors and patients to have a clear, evidence-based understanding of what might occur when antidepressants are stopped.

We should be clear about one thing regarding antidepressants and indeed all psychotropic medication: some people will consider themselves to be well-treated by antidepressants, and will not want to discontinue them. This analysis is not an argument for taking antidepressants away from people who feel they are highly effective. People who feel they are helped by using such medications should by no means stop using them just because some random Substack author said so.

What gets left barely acknowledged, however, is the existence of research suggesting that psychotherapy is at least as effective at treating depression than antidepressants. That was the clear conclusion of a 2005 study² comparing antidepressant medication efficacy against cognitive therapy (psychotherapy).

Cognitive therapy can be as effective as medications for the initial treatment of moderate to severe major depression, but this degree of effectiveness may depend on a high level of therapist experience or expertise.

Even though antidepressants do work for some patients, across broad patient demographics cognitive therapies are shown to work better for more people, and should be promoted over antidepressants.

Another study, this one from 2021³, found that treating depression with cognitive therapy to remission was more likely than medication to prevent relapse after treatment was ended (emphasis mine).

In the 50 years since it was first introduced, cognitive therapy has been shown to be as efficacious as antidepressant medications (on average) in the acute treatment of nonpsychotic depression, although some patients will do better on one than on the other. Moreover, patients treated to remission with cognitive therapy are less than half as likely to relapse following treatment termination as patients treated to remission with medications. However, a recent study suggests that adding medications interferes with any such enduring effect and medications themselves may have an iatrogenic effect that suppresses symptoms at the expense of prolonging the underlying episode.

Think on that emphasized portion for a moment. Mixing antidepressants with cognitive therapy could be hindering actual treatment and actually prolong the antidepressant episode.

Why are antidepressants still the “go to” for treating depression, despite evidence suggesting they are more of a problem than a solution? In a word, cost. Corporate media and the medical establishment freely acknowledge this:

Yet pills are often easier and cheaper: It can be hard for people to access therapy because there aren’t enough providers, and mental health treatments often aren’t fully covered by insurance.

Is the problem that we do not have enough therapists? Or is it possible we do not have enough friends? There is already good evidence that loneliness—itself both symptom and cause of depression—is on the rise and is taking a toll on people’s physical health. This despite the reality that loneliness should be the easiest of problems to resolve: quite literally people just need to be friendlier and to enlarge their circle of friends.

The Loneliness Epidemic

Yet we should also be mindful that social support systems and interpersonal relationships are not the province of counsellors and therapists, but of ordinary individuals. Not only is talking the best treatment for most mental health challenges, but talking among friends—in having the reassurance and support of committed friendships—goes a long way towards improving everyone’s mental and emotional health.

It is important to understand that the best therapies for resolving PTSD involve talking. While friends and other members of a person’s support network are not clinically trained therapists, and cannot provide the structured talk therapies available in the clinical setting, everyone has the capacity to listen, everyone has the capacity to create a safe and nurturing space where people can discuss their inner turmoil, and people grappling with trauma especially need that safe and nurturing space in which to talk.

Anyone can make a difference in someone else’s life simply by reaching out a hand of friendship. Simply by being a friend, each of us has it within his or her power to directly confront the loneliness and social isolation that is complicating everyone’s overall health outlook.

Nor is there much scientific dispute about the need for strong social support networks and good interpersonal communication for people grappling with the debilitating challenges of PTSD.

Childhood PTSD: The Other Side Of America's Mental Health Crisis

When we listen to people, when we make them feel safe about opening up regarding their inner turmoil, we give them space to address their trauma history and move that much closer to healing. When we validate that their traumas are real, that their inner pain is real, and that they are not “broken” or made less because of their experiences, we give them hope that real healing can be had.

Moreover, we should not forget that the evidence also suggests that one reason such mental health challenges are getting worse is because there is less “talking” and social interaction, particuarly from one generation to the next.

Teach The New Dogs Old Tricks

The growing body of evidence suggests that older generations have the tools, the life skills and life lessons, younger generations need to be better able to adapt and avoid being damaged or destroyed by their experiences of adversity—and those tools, life skills, and life lessons are not being transmitted to the younger generations.

People’s mental health is steadily declining generation to generation because the younger generations are simply not being taught the coping skills needed to buffer life’s many adversities.

The data is telling us that this societal lack of talking and human interaction is not merely making younger people more susceptible to mental health concerns, but it is also impeding the treatment of mental health concerns in every generation.

As June is PTSD Awareness Month, I am focusing my reading and writing for this Substack on issues of mental health specifically. This is a bandwagon worth getting on, to bring greater awareness to these issues, and also to bring awareness to the larger societal issues which the research data reveals.

We cannot eliminate all depression and mental health problems simply by spending more time talking to each other, and we should not pretend that we can. We can, however, go a long way towards mitigating and even preventing a good many mental health challenges simply by spending more time talking to one another. We can make mental health challenges less rather than more common, just by listening. Without spending a single dime on therapists or antidepressants, we can directly tackle the most common mental health issues confronting our communities.

Ordinary people are not therapists, and we should not require them to be therapists. However, even ordinary people can be a friend to someone, can listen to and be present for someone. There is no disputing the scientific and medical reality that lay people doing just that much for their fellow man would improve mental health outcomes across the board, but particularly form the common and escalating conditions such as depression.

There is also no disputing the reality that loneliness and social isolation—the polar opposites of what communities should be doing for their members—are negatively impacting people’s physical and mental health.

What the data is telling us, if we are but willing to listen, is that antidepressants are yet another class of medication that is overprescribed and even misprescribed.

What the data is telling us, if we are but willing to listen, is that we ourselves—ordinary people living ordinary lives—are an essential but largely neglected element of any effective treatment for depression.

Regardless of how simplistic it sounds, what the data is telling us is that we need to be more intentional about cultivating friends, and cultivating the social institutions—churches, civic clubs, hobby groups, et cetera—which help us to cultivate friends.

We can spend a little time cultivating friends and making our communities friendlier, or we can spend a lot of money on ineffective antidepressants because we do not have enough friends and we have not made our communities friendly.

A little time vs a lot of money: which expenditure do you choose to make?

1. Henssler, Jonathan et al. “Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis.” The lancet. Psychiatry, S2215-0366(24)00133-0. 3 Jun. 2024, doi:10.1016/S2215-0366(24)00133-0

2. DeRubeis, Robert J et al. “Cognitive therapy vs medications in the treatment of moderate to severe depression.” Archives of general psychiatry vol. 62,4 (2005): 409-16. doi:10.1001/archpsyc.62.4.409

3. Hollon, S. D., DeRubeis, R. J., Andrews, P. W., & Anderson Thomson, J. Jr. (2021). Cognitive therapy in the treatment and prevention of depression: a fifty-year retrospective with an evolutionary coda. Cognitive Therapy and Research, 45, 402–417. https://doi.org/10.1007/s10608-020-10132-1.