Blaming Prozac: The New Federal Attack on Antidepressant Medications

Antidepressant medications are one way to address symptoms of depression. They certainly aren't the only way, with psychotherapy having equivalent benefits in most cases, and exercise outperforming both of these options. I have also taken issue in the past with the way that antidepressants' beneficial effects have created a "brain disease" narrative around depression, which is about how we feel and behave more than it's about the way our brains are wired -- a functional problem rather than a structural one. Still, I recognize that antidepressants are lifesaving for many people, and I would never give blanket advice to suggest that people shouldn't take them. Some folks in the popular media right now are doing just that.

The question of whether or not it was a good idea to take antidepressants was common in the early 1990s, when Eli Lilly's new medication fluoxetine (Prozac) had revolutionized the neurochemical treatment of depression. The book Listening to Prozac presented case examples of people who felt that the mediation had allowed them to become their "true selves" even though they had never felt that way before taking the medication. And people started to talk about depression as a "chemical imbalance" in everyday discourse. An older "moral model" of mental health suggested that people should just think or live differently, and depression wouldn't be an issue -- an intellectual thread that has some relationship to stoic philosophy, and from there to cognitive-behavioral therapy. But after a while, the furor died down, the benefits of the new SSRI antidepressants seemed to outweigh their drawbacks, and they didn't work quite as well as originally advertised anyway. Whether or not someone was taking antidepressants became a private decision and largely irrelevant to the way we people thought about or reacted to them.

The debate over whether antidepressants are helpful or harmful has come back up in a major way because of the newly questioning stance that our Federal health agencies are taking toward psychiatric drugs. A May 4th "dear colleague" letter from Secretary Robert Kennedy's Department of Health and Human Services (DHHS) encouraged mental health providers to reconsider long-term use of psychiatric medications. Like many such Federal initiatives, the actual letter was relatively non-controversial, suggesting that "treatment should be individualized. Alternatives should be discussed. Medication regimens should be reassessed over time, and, when tapering or deprescribing is clinically appropriate, it should occur in a safe, thoughtful, and collaborative manner." But the statement has nevertheless drawn ire from mental health advocates. 

Last year around this time, an FDA panel considered whether to add greater safety warnings against the use of antidepressants for pregnant women, drawing negative reactions from organizations such as the American Psychiatric Association, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. These expert groups cite evidence that antidepressant use during pregnancy is generally safe, caution that the risks of depression itself may be greater than any potential medication risks, and dispute the Secretary's unsupported claims that prenatal antidepressant exposure causes later child behavior problems. Last September's DHHS report on autism, while focused mainly on the hypothesized risks of Tylenol during pregnancy, was released amid similarly overstated claims that prenatal exposure to antidepressants might also contribute to autism. And last summer's DHHS MAHA Report explicitly called for more research on whether children themselves taking antidepressants might cause behavioral problems like anxiety and ADHD.

Critics say that Secretary Kennedy's view of the problem is oversimplistic, and mention other public statements (not reflected in the "dear colleague" letter) in which he has said that SSRI antidepressants might be a cause of mass shootings. In a recent podcast episode, Secretary Kennedy interviewed writer Laura Delano, who is the author of the book Unshrunk: A Story of Psychiatric Treatment Resistance, and an advocate for people who want to stop taking their psychiatric medications. Ms. Delano related her story of feeling alienated from her adolescent life and from her own body, and said that she eventually came to realize some of her feelings were the effects of medications rather than signs of brain disease. She related a story of coming to accept herself and take on more agency for managing her own feelings day to day, rather than trying to medicate them away. The podcast also included a lot of conversation about the relationship between mood and healthy foods -- another of Secretary Kennedy's favorite topics.

Deciding how to think about antidepressants is tricky business. I certainly don't think that every person who experiences feelings of depression needs to get on medication immediately and stay on it for the rest of their life. I think it's a good idea to periodically re-evaluate any treatment to see if it's still helpful, and to de-implement those that are no longer necessary. And at the same time, I think that antidepressant medications are a powerful tool that can help people when methods like exercise and psychotherapy haven't worked or aren't feasible, when depressive symptoms are severe, or when fast symptom relief is needed. One can accept the empirically demonstrated benefits of antidepressants without buying into the medicalized "brain disease" model of depression. People's decision-making isn't helped by loading on stigma for people who do want to take an antidepressant, and it certainly isn't helped by tossing around unsubstantiated claims like the one about antidepressants causing increased violence in teenagers.

Ms. Delano's story of recovery seems quite healthy. But it's a long way from there to suggesting mental health treatments are always risky, or that they produce the very problems they are designed to address. Ms. Delano suggested that the problems she was attempting to medicate away were related to problems in her life, like a hyper-success-oriented school career and family interactions that were focused on appearance not substance. If instead of medicating people's reactions we were to address the underlying social causes of their distress -- things like capitalism, corporate exploitation, and environmental destruction -- then that might be a good thing, and perhaps many fewer people would need treatment. But expecting people to maintain their mental health without treatment, while continuing to uphold a world order that's fundamentally unhealthy, seems like we are simply taking away one of the few available tools that some people have to cope.