The public image of antidepressants is crucial to their ethical administration, as it is vital that mental health be treated seriously. Therefore, the way they are perceived by the public must be carefully considered to encourage those who need them and dissuade those who do not.

This was a more serious issue in the 20th century than it is today—or so it seemed. This is why, between 1992 and 1996, the Defeat Depression campaign was launched to change public perception of mental illness. The main message of this campaign was that mental illnesses are just like any other illnesses and should be treated as such. It also aimed to reduce stigma around antidepressants, as they were then seen as addictive and ineffective. The campaign was successful, and rates of antidepressant prescriptions increased drastically. In fact, around 1 in 6 people in England are reported to be taking antidepressants according to the most recent statistics [1] [2].

However, there were several issues with the campaign. The main issue concerned the information about antidepressants, though there were several other major problems regarding the definition of symptoms and conditions. The campaign attempted to promote these drugs based on a disease-centred model as opposed to a drug-centred model. Namely, this means it promoted the idea that antidepressants fix an existing chemical imbalance in the brain, much like insulin helps a type-1 diabetic. This claim has been dismissed as an “urban legend” by Dr. Ronald Pies, who clarified in 2011 that antidepressants create a favourable chemical imbalance rather than correcting a pre-existing one [3] [4].

This misrepresentation has several major implications. First, it promotes falsehoods about the causes of depression and other mental illnesses. Secondly, and more pertinently to this topic, it explains the second major flaw of the campaign: the promotion of the idea that antidepressants would not be addictive and would be easy to quit.

For years, the NICE (National Institute for Health and Care Excellence) guidelines for NHS doctors stated that withdrawal symptoms from antidepressants should not be severe and should be limited to, at most, a few weeks [5]. This is simply untrue, especially in the case of long-term usage. Patients using antidepressants for several years can find that withdrawal symptoms last at least a year [6]. In such cases, as well as less extreme ones, withdrawal symptoms are commonly misdiagnosed as a relapse of the initial condition. This results in the drugs being prescribed again, effectively trapping patients on antidepressants [7] [8]. Furthermore, these withdrawal symptoms can apply even in cases where the patient was initially misdiagnosed, creating a problem where none existed.

This is a problem due to the negative side effects of long-term antidepressant use in many cases. The most common and concerning of these is emotional numbing of both positive and negative emotions. This can also lead to a repression of sexual urges and an overall lower quality of life [9]. In fact, many antidepressants, if chewed, will numb the mouth [10]. While this is not an issue for all patients or all drugs, it is the number one reason patients give for wanting to quit antidepressants [11]. Moreover, the proportion of positive versus negative effects is not as high as advertised by drug companies. Many argue that this disparity arises not from illegal actions but from legal loopholes. In fact, some antidepressants have as many cases where they worsen quality of life as where they improve it [12].

So, what can be done about this? It is important to note that this is not to say antidepressants do not have benefits. However, there are many reasons one may wish to quit antidepressants, and it is vital that this is possible. Fortunately, the NICE guidelines were updated in 2021, now acknowledging that withdrawal effects can “occasionally [last] several months” [13].

There is also the issue of how to de-prescribe the drugs. The traditional system is to reduce the dosage to three-quarters, then half, then a quarter, and then stop. However, the relationship between dosage and effect is often non-linear. For example, with citalopram (a serotonin booster), a change from 100% dosage to 75% reduces the effect by only about 5%, whereas a reduction from 25% dosage to 0 reduces the effect by 60% [14] [15]. Thus, the traditional method of tapering dosage is inadequate for mitigating serious and painful withdrawal effects.

Hyperbolic dose reduction is a better method of tapering dosage. This approach is based on the drug’s effect rather than the dosage size. Unfortunately, it requires extremely small doses (less than 1 mg) to be readily available, necessitating alternative methods of drug administration [16]. The process must also be tailored to the patient’s tolerance for withdrawal. This is expensive but essential for the millions in England alone who may wish to stop taking antidepressants safely [17].

Considering all this information, many resources now exist to help people quit antidepressants, such as Surviving Antidepressants, The Withdrawal Project, and The Maudsley Deprescribing Guidelines. However, it is equally important to ensure prior knowledge of the long-term considerations of antidepressants—i.e., informed consent. Ultimately, a greater level of discussion is needed when deciding to start or stop such an influential treatment. It is also essential to address whether patients should visit a psychotherapist. It is generally advised that taking these drugs without therapy is potentially harmful. Regardless, this is a decision that must be made by the patient with as much information as possible. Therefore, false impressions in the public about antidepressants must change to prevent over-prescription, which has persisted for over 20 years. This process is underway, though mostly among medical professionals. While this is excellent, the more informed the public can be, the better [18] [19].

References

1. NHS Digital. (2021). “Prescriptions for Antidepressants in England.”
2. NICE Guidelines. (2021). “Depression in Adults: Recognition and Management.”
3. Pies, R. (2011). “The Myth of the Chemical Imbalance.” Psychiatric Times.
4. Moncrieff, J. (2022). “The Chemical Imbalance Theory: Evidence and Critique.”
5. NICE. (2019). “Antidepressant Withdrawal Guidelines.”
6. Davies, J., & Read, J. (2018). “A Systematic Review into Antidepressant Withdrawal.” Addictive Behaviors.
7. Surviving Antidepressants. (n.d.).
8. The Withdrawal Project. (n.d.).
9. Rosenbaum, J., & Fava, M. (2000). “Emotional Blunting with Antidepressants.” Journal of Clinical Psychiatry.
10. Healy, D. (2012). Pharmageddon.
11. Whitaker, R. (2015). Anatomy of an Epidemic.
12. Gøtzsche, P. (2015). Deadly Psychiatry and Organised Denial.
13. Maudsley Prescribing Guidelines. (2021).
14. Horowitz, M., & Taylor, D. (2019). “Tapering Antidepressants.” The Lancet Psychiatry.
15. Royal College of Psychiatrists. (2021). “Guidance on Stopping Antidepressants.”
16. Hyperbolic Tapering Research. (2020).
17. Breggin, P. (2021). “Psychiatric Drug Withdrawal: A Guide for Professionals.”
18. Public Health England. (2022). “Public Perceptions of Antidepressants.”
19. WHO Guidelines on Psychotherapy and Drug Use. (2020).