Illustrations: Dan Howden

Everyone is on Antidepressants Right Now. Is That OK?

Medication can be life-altering — for those who actually need it

At first, Lisa, a writer in Minneapolis, experienced a “honeymoon period” of quarantine. “I was good at finding amusements like sketching, creating little things to look forward to like takeout from a favorite restaurant,” she says. But weeks in, “I hit a wall. My work dried up for a while. I struggled with feelings of isolation and uncertainty about the world. Everything felt meaningless. I was without the usual ways to keep sociable or distract myself. I stopped even setting my alarm. Why get up?”

Lisa had been seeing a therapist for several years for help managing her anxiety and had learned “mostly healthy coping skills,” she says. “But this hopelessness felt difficult to manage on my own. The world felt heavier. I thought, ‘I can do all the yoga and meditation and journaling in the world, but I will still be in that hopeless place.’” Her therapist thought Lisa was suffering from depression and encouraged her to try medication; a nurse practitioner at her doctor’s office prescribed Lexapro, a commonly used selective serotonin reuptake inhibitor (SSRI) antidepressant.

Lisa has lots of company. In June, the Food and Drug Administration made headlines when it added the SSRI Zoloft to the drug shortage list. Prescriptions for antidepressants and anti-anxiety and anti-insomnia medications shot up 21% between February and March 2020 alone, according to industry data. Even before the world turned upside down, a whopping 11% of Americans in 2019 were taking an antidepressant.

Are antidepressants… “medicalizing” a perfectly rational reaction to this unprecedented shitstorm?

Psychiatrists point out that this current leap in scripts is not all first-timers like Lisa, newly driven to despair by Covid-19. According to Jessi Gold, MD, an assistant professor of psychiatry at Washington University School of Medicine in St Louis, “the rise is partly due to current patients needing their doses increased and returning patients going back on treatment who had been feeling good for a while.” The good news is that many people are seeking needed help. Yet this huge increase also raises important questions: Are antidepressants such as Zoloft essential medications in a time of immense psychic misery? Or are they overprescribed and “medicalizing” a perfectly rational reaction to this unprecedented shitstorm?

An epidemic of misery

There is no question the Covid-19 pandemic has taken an enormous emotional toll. Currently, a quarter of Americans describe some symptoms of clinical depression, according to data from the Centers for Disease Control and Prevention. In fact, researchers at the University of Washington warn we should prepare for an “epidemic” of clinical depression.” The distress we feel is a normal human response to a severe crisis,” write the researchers. “Acknowledging and accepting these feelings prevents distress from turning into disorder.” Adds Gold, “Your emotions may be all over the place. When it seemed like quarantine would be over in a few weeks, a lot of us thought, ‘OK, I can do this.’” But now, months in, both our civic resolve and daytime pajamas have frayed: “As this goes on with no certain end, I am seeing some people spiral downward,” Gold says.

Diagnosing milder cases that might benefit from medication is more complicated — an admixture of art and science.

Ashley Kendall, PhD, a clinical psychologist and the founder of Chicago CBT & Mindfulness, is also seeing lots of people struggling right now. “This is an incredible stress on the system,” she says. “The odds that you would be feeling the same way you did before the pandemic are slim to nil. If you’re feeling anxious, if you’re feeling depressed, that’s entirely reasonable in a lot of senses. It’s also perfectly reasonable to reach out for help.”

Yet at what point does your feeling awful about the world tip into a medical diagnosis that drugs are indicated for? Depression exists on a spectrum. When it is severe, it immobilizes people with grief or haunts them with thoughts of suicide and is a clear medical emergency. People with a medical history of depression or anxiety may have a significant return of these conditions now. But diagnosing milder cases that might benefit from medication is more complicated — an admixture of art and science. Unlike appendicitis or diabetes, scans and blood tests cannot deliver a clear verdict. Depression is often mixed with anxiety, which SSRIs also target. While there are official diagnostic criteria, symptoms are open to interpretation by clinicians: What is a normal reaction to a life stressor, and what is a sign of disorder? “You need to consider context. Someone could be sleeping a lot right now not because they are depressed but because they are home more and simply bored,” says Michelle Riba, MD, associate director of the University of Michigan Comprehensive Depression Center.

Also complicating diagnoses now are that behaviors that might traditionally signal a disorder — drinking too much, lack of pleasure, never getting off the coach, isolating oneself, overeating — are how many of us are living while quarantining. “Events like 9/11 taught us that there may not be a ‘normal’ response to stressors of this magnitude and that understandable responses depend on individual factors like exposure to previous trauma or resilience,” says Joseph M. Pierre, MD, the acting chief of mental health community care systems at the VA Greater Los Angeles Healthcare System.

As a psychiatrist, Riba conducts a detailed medical and psychiatric history and asks new patients about issues like substance abuse, social support, and current life stressors before deciding whether to prescribe medication. But there’s a shortage of psychiatrists in this country. Primary care docs, long the main prescribers of this class of drugs, don’t always have the luxury of conducting such a detailed workup in the 15 minutes typically allotted. Appointments via telemedicine make a subtle diagnosis in the best of times even more challenging. “This is an unprecedented situation. It is new territory for all of us,” says Tracey Marks, MD, a psychiatrist in Atlanta.

Listening to Zoloft

Treatment recommendations for depression typically include some combination of therapy and drugs. And today, Zoloft and other SSRIs are considered a first-line medication. As a class, SSRIs skyrocketed in popularity in the 1990s after psychiatrist Peter Kramer published Listening to Prozac with its message that the drug could be downright transformative, making people “better than well.” Unlike earlier antidepressants such as monoamine oxidase inhibitors and tricyclics that required careful monitoring, SSRIs were thought to be much safer, so primary care doctors were more comfortable prescribing them, making them more accessible.

“We love the idea that a messy, complicated thing like mental health can be explained and solved so neatly.”

Yet even decades later, experts are still not sure how — and indeed if — SSRIs work. Serotonin is a neurotransmitter that, among other functions, helps brain cells communicate and is associated with mood and well-being. SSRIs work by blocking reabsorption so that more is available in the synapse between cells, allowing cells to communicate better, explains clinical pharmacist Margaret Tsopanarias, “but the exact mechanism is not fully understood,” she says. Marks agrees: “We’re targeting the neurotransmitters with these drugs, but that might not be the only place to address. We are currently also investigating the possible role of hormones, of the hypothalamus, in depression. It is a big iceberg, and we have only been chipping away at the part we can see.”

Drug manufacturers helped advance the shaky but widely embraced theory that a simple “chemical imbalance” is the chief cause of depression — easily fixed by ingesting the right drugs. As a society, we have latched onto this premise, says Dena T. Smith, PhD, a professor of sociology at the University of Maryland, Baltimore County. “We love the idea that a messy, complicated thing like mental health can be explained and solved so neatly.” According to Gold, “usually the reasons for depression are multifactorial. There’s a biological component, a psychological component, a social component. You might be predisposed to depression, and now you find yourself feeling isolated, working from home while taking care of your kids. All these factors interact.”

Despite SSRIs’ astounding popularity, scientific evidence for their effectiveness has been mixed. Decades after they came into widespread use, a landmark 2008 meta-analysis out of Harvard found antidepressants were no better than placebos in treating depression. Recently, though, a large 2018 meta-analysis in The Lancet showed antidepressants, including SSRIs, were in fact more effective than placebos after all. SSRIs may be most useful for patients with the most severe cases, the Harvard study found. What they do for milder, and possibly temporary, cases is less clear, and some experts are cautious.

“There can be little doubt that antidepressants are being prescribed for [simple] unhappiness,” says Joel Paris, MD, a researcher and professor of psychiatry at McGill University. “Patients ask for them, and MDs want to ‘do something’ to help. But these drugs are most useful for moderate or severe symptoms of depression and anxiety. They are not significantly better than placebo for mild symptoms. Of course, the placebo effect is very powerful.” Once you start these drugs, patients and doctors can be reluctant to stop them, adds Paris, who notes there isn’t good data on antidepressants’ long-term effects. A March 2020 study highlighted the difficulty some people have in withdrawing from antidepressants.

But while mysteries remain, doctors see patients every day who have been enormously helped by these medications. “The reality is that psychiatric symptoms like insomnia and anxiety can often respond to medication regardless of its cause or connection to a social stressor,” says Pierre. I can personally attest to their benefit. I have been taking Zoloft for the past year for panic disorder. During these last turbulent months, my mood has been more Mona Lisa than The Scream. Things that once would have set off a full-throttle panic attack now throb briefly then slide off my Teflon brain. I feel an undeniable alchemy going on that a placebo effect alone can’t explain. My dreams are much more vivid. At the same time, I feel pleasure less keenly. The occasional catharsis of tears is much more elusive.

A medical model

While the leap in prescriptions for antidepressants during Covid-19 has been dramatic, it can also be viewed as part of what some critics say is a larger cultural trend of treating life’s complexities with a pill. “The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) classifies more of human behavior, thought, and emotion as an illness than ever before,” says Smith. Social anxiety disorder once was simply called shyness, for instance — now it is a condition that can be treated with medication. “I would argue this larger cultural push to medicalize emotions is partly due to the abundance of pharmaceuticals out there. We see ads for them on the evening news; they are pushed at us on Facebook. Right now, we may be experiencing messy, uncomfortable feelings. No wonder we gravitate to a medical model to solve them,” says Smith. In a 2014 paper critiquing how depression is treated, Paris wrote: “Psychiatric diagnosis, encouraged by the pharmaceutical industry, has been expanded, medicalizing normal distress in a way that has been called disease-mongering.”

“During this uncertain time, our minds can run pretty wild. The less reactive we are to our own minds, the better off we tend to be.”

Drew Ramsey, MD, a psychiatrist and assistant clinical professor of psychiatry at Columbia University College of Physicians and Surgeons, draws on lifestyle changes, therapy, and medication in treating his own patients. “Zoloft is a very safe antidepressant. I have prescribed it for hundreds of people. But no one in mental health views these drugs as a cure-all. It doesn’t help you work through trauma, it doesn’t give you new skills, or understand your personal strengths and weaknesses. In many cases, I look to other ways to manage symptoms first: diet, mindfulness, improvement in sleep hygiene, psychotherapy. Until those other modalities have been tried, or it’s been established those other modalities are not possible, medications aren’t an appropriate choice.”

Talk therapy might not have as skilled a publicist as the Zoloft blob. But research suggests cognitive behavioral therapy and similar approaches can be as or more effective than medication in many cases of depression. Therapy is also powerful in combination with drugs, resulting in more enduring change: “You are less likely to relapse as you are learning coping strategies you can use in the future,” says Kendall.

“There’s value to simply observing your thoughts and feelings without immediately viewing them as a problem that needs to be solved,” notes Kendall. “During this uncertain time, our minds can run pretty wild. The less reactive we are to our own minds, the better off we tend to be.” Indeed, a 2019 study found that practicing this kind of distanced approach through mindfulness practice reduced symptoms of both depression and anxiety.

Getting good help

Accepting feelings of sadness and grief as normal right now doesn’t mean you should just tough it out. “There’s no reason to suffer. If you are worried about yourself or a loved one, it’s really good to seek professional advice,” says Riba. Some signs: Your symptoms, such as feelings of hopelessness, insomnia, or loss of concentration, last more than two weeks or so, are severe, or interfere with your daily functioning — your work or caring for family members. (Thoughts of self-harm or harming others are a medical emergency.) Depression can also manifest as physical symptoms such as stomachaches, muscle aches, headaches, and fatigue according to Chris Coller, DO, a physician at Parsley Health.

Sometimes, symptoms may respond to conscientious self-care. “Our brains take cues from our bodies about how we should be feeling,” says Kendall. Getting back to regular sleep, reaching out to friends, eating things besides banana bread, and exercising can all be very helpful. “I suggest patients get up and do one productive thing first thing in the morning — answer that email, go for a run. That can help your mood for the rest of the day.” Coller also suggests reducing constant media consumption: “I’m not saying be naive to what’s going on in the world. But take a break from that constant negativity and see how much better you feel.”

If your doctor does suggest antidepressants, ask what you can expect, says Tsopanarias: “These are not happy pills. They won’t have you instantly singing in the rain, sliding down rainbows. The goal is to get you feeling like your old self again.” SSRIs can take weeks to work and may require tinkering with dose or trying another kind. Initial side effects often subside but may cause some patients to stop on their own. Communicate about any concerns instead of just bailing. Riba adds, “As a psychiatrist, what really worries me is how many people are actually using them six weeks later or three months later. They may stop and never tell their doctor. There needs to be good follow-up.”

In the end, antidepressants can be an imperfect yet important tool, experts agree. A month after taking her first Lexapro, Lisa reports: “I’m not nearly in as bad of a place as I was. It’s hard to know if it’s because of the pills or because the time has passed and I would have come out of it by now anyway. I think I am feeling better … but it’s early.”

If you are in crisis and in need of urgent help, please contact the National Suicide Prevention Lifeline at (800) 273–8255.

writes about health and psychology for O, Real Simple, Health, Prevention, and many other outlets. South Bend, Indiana. jenniferkinglindley.com

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