The honest conversation about antidepressants I wish my psychiatrist had with me

If you’ve been taking antidepressants or anti-anxiety medications for years, you might have certain questions. Do you still need the medication? How would you know if you didn’t? Does it make sense to stay on it indefinitely, or do you owe it to yourself to see what life would be like without the medication?

I don’t believe any of us has one true self, so I don’t think you can “owe” it to a central self to act in this way or that. Instead, I offered an alternative way of approaching this dilemma in a recent installment of my Your Mileage May Vary advice column. 

But beyond the philosophical question of what you do or don’t owe yourself, there are medical questions that might still gnaw at you. Some people worry, for instance, about the withdrawal symptoms they might experience should they try to taper off selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed type of antidepressant. Others worry that perhaps they’ve become dependent on a drug and are not sure how to feel about that.

Since I have no medical training, I can’t give medical or psychiatric advice. But one of the most interesting voices tackling these questions is Awais Aftab, a psychiatry professor at Case Western Reserve University School of Medicine. I came across him through his insightful newsletter, Psychiatry at the Margins, and a piece he wrote for the New York Times calling for psychiatry to engage honestly and transparently with patients’ concerns about antidepressants, rather than ceding that conversation to those — like RFK Jr. and the MAHA movement — who would exploit it for political ends.

Aftab is critical of the psychiatric establishment’s failings, but he doesn’t throw the baby out with the bathwater; he is very aware that for some people, antidepressants can be lifesaving. I reached out to him because I knew he’d have a nuanced take on all these questions — some of which have niggled at me as someone who’s been taking an anti-anxiety medication for years. Our conversation, edited for length and clarity, follows.

Why are so many people unsure how to think about the meaning of taking antidepressants, especially long-term? Are most psychiatrists failing us in some way? Or is ambivalence just an unavoidable feature of living at a time when medical progress keeps handing us choices that come loaded with tradeoffs?

I think it’s both, honestly. Let me start with the deeper issue. Medical progress keeps giving us more and more control over aspects of our lives, such as our moods, our anxiety, our emotional reactivity, but that control is imperfect and comes with genuine tradeoffs. [The philosopher] Bill Fulford has articulated the idea that scientific progress creates new technologies which create new choices for us, and this increasingly brings the full diversity of human values into play. More choices mean more uncertainty, more ambivalence. That’s just the moral cost of living in a world where these options exist. 

“We can choose to take antidepressants or not, continue them or stop them, but we can’t choose not to have the choice. And the uncertainty is genuine.”

We can choose to take antidepressants or not, continue them or stop them, but we can’t choose not to have the choice. And the uncertainty is genuine. “Are the drugs helping?” “Do I still need them?” aren’t always easy questions to answer for any specific person.

That said, too few clinicians are attuned to any of this. Most psychiatrists aren’t trained to explore the meaning and emotions patients assign to their medications. Patients can feel relieved by symptom improvement and simultaneously detest feeling dependent on a pill. They may credit the drug with saving their life and still wonder who they’d be without it. When clinicians don’t anticipate and directly address that ambivalence, patients are left to navigate it alone.

The goal should neither be to nudge people toward staying on medications or encourage them to discontinue, but to support them in making decisions that align with their own priorities. That requires a kind of clinical attention most people just aren’t getting.

If someone says to you, “Look, I’ve been on these meds for years, and at this point I honestly can’t tell whether they’re still necessary” — what would you advise them to do?

I’d say: That uncertainty you’re feeling is completely legitimate, and you’re not alone in it. A lot of people on long-term antidepressants feel this way. What I’d recommend depends on multiple factors. Their mental health history is especially relevant. Someone who’s had multiple severe depressive episodes with hospitalizations has a very different risk calculus than someone who started an SSRI for mild anxiety five years ago and has been stable since. The subjective meaning matters too. Some people are at peace with taking a daily medication; for others, it gnaws at them. Some patients would rather stay on a medication and minimize any chance of relapse or deal with withdrawal; others are determined to find out whether they still need it, even if that means going through some rough patches.

What I recommend to my patients is the courage to make an informed choice — to continue or taper, whatever the case may be. A lot of people stay on antidepressants because they’re stuck in a kind of ambivalent inertia. Years pass while they wonder what their life would be like without the drugs, whether they’d feel more brightly, think more creatively, have a more intimate sense of their own resilience.

If someone wants to stop their meds, it should be done carefully, with clinical help and with a slow taper. If someone has been on SSRIs for years, a cautious taper would take several months at least. But I also want to be honest: A slow, gradual taper is not easy because it often requires using doses that are not available in standard pills available at pharmacies, which means people at times have to use liquid versions of the medications or use expensive compounding pharmacies. There is also no agreement in the psychiatric field right now about the best tapering protocols, and patients will encounter all sorts of guidance online.

How common is it for people who take antidepressants for years to form either a physical dependence or a psychological dependence on them? What does each kind of dependence look like?

Physical dependence on antidepressants is a well-established phenomenon. Your body adapts to the presence of the drug, and when you stop or reduce the dose, you can experience withdrawal symptoms, like dizziness, nausea, “brain zaps” (an electric shock-like sensation in the head), vertigo, irritability, insomnia, and sometimes a rebound of anxiety or mood symptoms that can be difficult to distinguish from a relapse of the original problem. Most people who have been on antidepressants for years will experience some degree of withdrawal, although severe withdrawal appears to be less common. Some people have also reported protracted withdrawal online, lasting months or even years, though this remains poorly understood.

Psychological dependence is more about the anxiety of going without it. Once you’ve internalized the idea that you need the pill to feel okay, it can feel almost impossible to stop. Why run the risk? Why open yourself up to withdrawal, to a possible return of depression or anxiety? This is understandable, but it can keep people on medications for years and decades more out of fear and inertia than any active choice. My view is that such psychological dependence shouldn’t be ignored by clinicians and any distorted worries and fears should be addressed.

One thing that confuses some people is whether it makes sense to think of this dependence in terms of “addiction.” Some people reason that if they experience withdrawal symptoms when going off the pills, that means they’re addicted to the pills in some way. Is addiction the wrong frame when thinking about antidepressants?

Yes, addiction is the wrong frame. Addiction in the clinical sense involves compulsive use of a substance despite harmful consequences, quickly escalating doses to achieve the same effect (tolerance in the classic sense), craving, and loss of control. Antidepressants don’t produce any of that. People don’t crave antidepressants the way someone addicted to opioids craves opioids.

What antidepressants can produce is physiological dependence. The body adapts to the drug’s presence and reacts when it’s removed. The confusion with addiction is understandable. If you experience withdrawal symptoms when you stop a substance, the intuitive conclusion is “I must be addicted.” But dependence and addiction are different phenomena medically. Many medications can produce physical dependence without being addictive.

That said, I’m sympathetic to why people reach for the addiction frame. When you’re experiencing terrible withdrawal and you feel trapped on a medication you want to stop, the language of addiction becomes appealing and powerful. But clinically, it’s not accurate, and using that becomes confusing and stigmatizing.

My own psychiatrist once told me that my SSRI is not the kind of drug where it makes sense to worry about addiction. She said that instead, I should put it in the mental category of “if you have high blood pressure, you take blood pressure medication.” Is that a more accurate way to think about it? 

Your psychiatrist is right about the core point: Antidepressants aren’t addictive in the way that, say, opioids or benzodiazepines can be. Putting them in a different mental category from drugs of abuse is appropriate. But the blood pressure medication analogy is limited in its own way, and I think it can be misleading if taken too far. 

With most blood pressure medications, if you stop taking them, your blood pressure goes back up and possibly may even shoot up higher than what it used to be, but you don’t experience a distinct withdrawal syndrome with symptoms you hadn’t previously experienced. With SSRIs and other antidepressants, stopping can trigger symptoms that are distinct from a return of depression or anxiety. Like dizziness, brain zaps, nausea, electrical sensations, severe irritability. For some people, these symptoms are mild and brief. For others, they’re genuinely debilitating.

Why has the psychiatric establishment been slow to research withdrawal struggles? What would fixing the research gap require? 

The failure here is multilayered. Part of it is a funding problem. Federal research funding in psychiatry has been heavily tilted toward basic neuroscience and drug development, understanding the brain, finding new molecules, at the expense of studying the everyday clinical realities of how people actually experience medications, including what happens when they try to stop. Tapering and deprescribing just aren’t where the prestige or the grant money has been. Nearly four decades after the approval of Prozac, there is not a single high-quality randomized controlled trial that compares specific methods of tapering patients off antidepressants. That’s a remarkable gap.

Part of it is ideological. There’s been a prevailing attitude in psychiatry that withdrawal is rare and mild, “low on the list of priorities,” as a group of prominent psychiatrists once put it in a letter to the New York Times. This dismissiveness has been enormously damaging. Patients who experience severe withdrawal have been told it’s just their depression coming back, or that what they’re experiencing isn’t real. Clinicians who are trained to see medications primarily as solutions naturally have difficulty recognizing them as sources of harm.

Part of it is methodological. The tools we have to measure withdrawal are inadequate. We don’t have good ways to distinguish withdrawal from relapse. We don’t know what tapering strategies actually work best under rigorous conditions.

Fixing this would require making research into iatrogenic harm, that is, harm caused by medical treatments, a genuine funding priority. It would require developing better measurement tools, running proper tapering trials, updating clinical guidelines, and training clinicians to take deprescribing as seriously as prescribing. Deprescribing should be the bread and butter of every working psychiatrist, not outsourced to fringe critics of the profession.

Speaking of critics of the profession, how do you see the MAHA movement and RFK Jr. fitting into this? Is their war on antidepressants complicating psychiatry’s ability to course-correct?

I’m deeply concerned about the direction of that movement. RFK Jr. has said things about antidepressants that resonate with many people who’ve been harmed by them. He’s echoing language that has circulated in prescribed-harm communities for a long time. But RFK Jr. and the MAHA movement are not equipped to navigate the clinical and scientific complexity here. Their political agenda and funding decisions will not lead to better research and better clinical care. They will, in all likelihood, lead to confusion, distrust, stigma, polarization, and possibly restricted access to medications for people who need them.