Antidepressants, physical dependence, and semantics

Antidepressants are a very useful class of medications. With the introduction of the first modern antidepressant, fluoxetine (Prozac) in the U.S. in the late 1980’s, the pharmacologic treatment of depression has undergone a revolution (and an enduring controversy). Older classes of antidepressants were often effective, but came with a host of unpleasant toxicities—MAOIs can lead to potentially fatal interactions with certain other drugs, and even foods, and tricyclic antidepressants, when misused, can lead to fatal overdoses. Prozac, the first of a new class of medications known as SSRIs (later followed by similar classes such as SNRI’s, etc.) appeared quite safe and effective. Side effects were minimal, and overdoses were rarely fatal. But as newer SSRIs were introduced, it became apparent that while treatment with these drugs was quite safe, stopping these drugs was not always pleasant.

The issue has to do with what is known as “antidepressant discontinuation syndrome”. When many of the newer classes of antidepressants are abruptly discontinued, there is a constellation of symptoms that many patients experience, including headache, dizziness, muscle aches, and nausea. This isn’t one of those “iffy” adverse drug events, for example when a patient treated with a statin complains of a backache and blames the drug. This is a predictable reaction to stopping or skipping a dose of medication. These drugs obviously alter brain chemistry (and not unlikely, physiologic processes in other parts of the body), and their sudden cessation causes discomfort. Moreover, resuming the medication relieves these symptoms. In other words, stopping these medications can cause a withdrawal syndrome. Why don’t we just call it that? What’s with this “discontinuation syndrome” thing?

I love going to the companies websites—it’s probably the worst possible way to find useful drug information, which makes it fun to pick over and see what patients are going to ask me later. Let’s see what the Zoloft people have to say in their FAQs:

Is Zoloft addictive?

No. In medical studies, it has been shown that Zoloft is not addictive or habit-forming.

Then, further down:

Side effects may result from stopping Zoloft particularly when abrupt.

I think I’m getting the picture here. Addiction, a negative set of behaviors that accompany some types of drug dependence, is a nasty, dirty, horrid little word. It is true that Zoloft is not addictive, in the sense that those who are dependent on it don’t normally develop negative behaviors such as seeking out the drug inappropriately, and it is also true that SSRIs don’t induce euphoric symptoms, like many addictive substances. But many tobacco and heroin addicts also have no real high anymore, and simply use to avoid withdrawal.

It is very, very bad marketing to admit that your drug causes physical dependence, and even worse if you use the “a” word. It is also difficult to prescribe a drug if the “a” word is thrown around (unless of course it’s an opiate, in which case it’s, “gimme gimme gimme now”).

But if we are honest about how we discuss these things, we need to admit that SSRIs and other newer antidepressants cause physical dependence. This dependence rarely if ever leads to negative sets of behaviors, and the withdrawal isn’t deadly (as alcohol or amphetamine withdrawal can be), but it is real, and must be figured into the clinical calculation. It almost certainly needs more study.

Let’s start using the real words for things—our patients can handle the truth.


45 responses to “Antidepressants, physical dependence, and semantics”

  1. Not only can they handle the truth, but what damage is done by having them figure out on their own that their doctor or “Big Pharma” obscured any facts about their meds?

  2. Frasque

    Thank you, I’ve been saying this for YEARS. This is exactly why I’ve refused to take antidepressants, not to mention doctors seem eager to dope me up after knowing me all of ten minutes.

  3. I did say that these are very useful medications…but we have to be very aware of the fact that physical dependence is an issue, and they must be weaned by a professional. Reliability of the patient may also be more important than we think because if the patient is non-compliant and runs out of meds, they may be truly miserable, and perhaps in some circumstances would have done marginally better without the drug.

  4. Anonymous

    One thing about this is when the insurance company won’t re-fill a prescription until the very last minute and you are running out of pills. I don’t know how many times we got a few “free samples” from our pharmacist to tide us over to the next month. You also can get bad symptoms when attempting to change SSRIs and finding the right one can be quite the science “experiment”. The sexual side effects can be quite pronounced, also. This particular issue is more pronounced for women because there are not good treatments for this although off label use of Viagra worked for my wife.

  5. I agree that the concept of physiologic dependence shouldn’t be stigmatized. Addiction results from a combination of physiologic and psychologic dependence on a substance, and isn’t inherently amoral either, though the stigma is more understandable since the overwhelming majority of addictions have negative results.

  6. I’m sorry, I meant “inherently immoral.” I think many addictions, particularly to prescription meds prescribed properly for medical use are amoral.

  7. GSK European Promotion of Medicines Code of Practice

    Clause 4 Promotion and Its Substantiation

    Page 10. Clause 4, 4:10

    “It must not be stated that a product has no side-effects, toxic hazards or risks of addiction or dependency.”

    “These tablets are not addictive” and “Remember you cannot become addicted to Seroxat.”
    Seroxat Patient Information Leaflet 1996

    “It was quite clear from talking to patients and as a doctor that’s very, very important to me, it’s quite clear that the phrase ‘Seroxat is not addictive’ was poorly understood by them.”
    Dr. Alastair Benbow
    Head of European Psychiatry for GlaxoSmithKline

    “Everybody who has looked at this the FDA, American Psychiatric Association, National Mental Health Association all those groups agree that SSRIs, like Paxil, are not addicting and not habit forming.”
    Andrew T. Bayman
    Attorney for GlaxoSmithKline
    King & Spalding

    “These problems [‘discontinuation reactions’] are just the body’s adjustment when you stop taking medicines. It takes more than that to be addictive.”
    Mary Anne Rhyne
    GlaxoSmithKline spokesperson

    And the medicine regulators stance [MHRA] on addiction?

    See here –


    Seroxat Sufferers Author

  8. I really don’t know anything about this, so I’m looking at it from a layman’s point of view. So I’m happy to be enlightened by better informed folk!

    To my layman’s mind, the use of the word “addictive” implies that if I take the drug long term and become addicted, then stop taking the drug, I can expect to get huge cravings for it, “want some drug, want some drug, want some drug,…”.

    On the other hand, saying that when I come off a drug I might feel lousy for a few days is something different, and does not necessarily I’ll have cravings for the drug. It’s just a transient side-effect.

    Am I missing something? If the Evil Pharma Pholk are trying to pretend that A is not-A, of course that’s bad!

  9. I agree with Sam C that addiction means something different to the layman than to the professional. It seems like we should have a way of explaining this to patients that doesn’t stigmatize SSRI use in the way that using the word “addiction” would.

    I’ve taken both Prozac and Zoloft and I’ve experienced a few of the withdrawal effects. I know that when I go off an SSRI, it has to be done veeeeery slowly.

    But four years ago, Zoloft literally (not figuratively) saved my life and quite possibly the life of my brand new baby, so I think I can put up with a little bit of discomfort if I decide to stop taking it!

  10. Great explanation and way to lay it all out. It’s great to see the truth being spread about these drugs. As the author indicated, antidepressants are not all bad, they’ve been helpful.

    However, people should have the right to make an informed decision about what chemicals they put in their body.

  11. Wow, this is going somewhere i totally didn’t expect.

    Let me reiterate that SSRI’s are great drugs, and not addictive, but there is a physical tolerance/withdrawal syndrome associated with them. They are hardly the only drug we use that is associated with dependence but not addiction. As for me, knowing this allows me to tell my patients what to expect…it doesn’t keep me from prescribing them, just as i warn them about the high rates of sexual dysfunction associated with treatment.

  12. Right, all it means is that you don’t need to quit SSRIs cold-turkey, you need to have your doc step down your dosage and wean off them over a few months, should both of you decide you no longer require them. This, to me, as a layman, means something substantially different from “addiction.” I feel fine about taking Paxil, but I avoid Xanax, y’know? (Also, I think the street value of my Paxil is pretty low. ;))

  13. What if the medication suddenly becomes inaccessible? There is a blogger at who had to switch from Effexor tablets (IR/Instant Release I assume) to Effexor XR because she lives in Brazil and they were pulled from the market. On her blog she talks about the terrible side effects she’s had switching to the XR.

    What if one of these drugs gets recalled in the United States for some reason? It’s unlikely there would be much support, if any, for all the patients who were prescribed the drugs.

    As Eli Lilly and GlaxoSmithKline have suppressed data that showed a higher incidence of suicidal behavior or other SAE’s in children and adolescents (the warning was later expanded to adults up to 25 years old) from taking their “medicine” than on placebo, it shows an extremely poor level of concern for human beings. Especially since the drug was marketed as effective for children even though trials didn’t show a statistical difference than placebo.

    In the preceding scenario, the risks simply and most definitely are NOT worth it, in my opinion. I don’t have children, but once parents have complete and accurate data, I’ll most happily keep my opinions to myself. I find that many people still do not understand or fully comprehend the the physical dependency issue associated with SSRI medication, nor the risks for suicide as a side effect or a withdrawal symptom. And most doctors do not care to make an attempt at separating depressive symptoms or anxiety from side effects or withdrawal symptoms.

    People are far too trusting of doctors to obtain essential information, but I for one have had several doctors over the years, at least six, and there’s a common theme among them all: Give them the drug, don’t encourage them to ask questions, schedule one appointment every six weeks, don’t encourage calls from patients after hours or even between appointments. Not only are people with mental health issues, desperate people, taken advantage of, but anyone who will blindly trust doctors to do the right thing, and think that money isn’t involved, and conflicts of interest do not exist.

  14. there is a significant percentage of the population who when they try to withdraw from these drugs have horrible life-altering experiences…try spending some time with people who have had these experiences and tell them it’s not an addiction…

    and it’s not just antidepressants…I’ve had severe withdrawal issues with multiple psych meds and have now had contact with thousands of others who have too…

    My issues are predominantly PHYSICAL withdrawal syndromes of some kind..not psychiatric issues…

    dependence vs. addiction is called splitting hairs.

    the pharmaceutical junkie has their dealer easily accessible…if one were to lose their source and cold turkey off some of these meds they might just start acting desperate too—like a street addict. Only thing is most people don’t even know why their so sick when their source runs out and often doctors don’t recognize it either…it gets labeled, often times, yet another psychiatric condition.

  15. I’d have to agree with you that the line between dependence and addiction is sometimes unclear—but real normative differences exist.

    The fact that a drug has a potential adverse effect associated with it should not close the door on its use—but it should give us pause, and cause us to follow our patients closely.

  16. Kristan

    There really is a huge difference between addiction and dependence. For instance, only 10% of the people that use opioid pain “killers” will become addicted to them….BUT any patient that takes these drugs (for long periods of time) will become dependent on them and suffer from withdrawal.

    The difference between addiction and dependence is further complicated by the DSM which uses the definition of addiction but calls it dependence. I believe in newer versions of DSM the term “dependence” will be replaced with the term “addiction” which should help with the confusion.

  17. Big Pharma is not truth oriented in its public communications. I know because I worked in the pharma advertising industry.

    That said, even professionals implicitly recognize a distinction between addiction and physical dependence in some contexts. Otherwise, they’d say that everyone who takes opiates for an extended period is an addict. Clearly, that’s false–even though many of those people would experience withdrawal if they stopped suddenly.

    Some of the most addictive drugs don’t cause withdrawal symptoms, even in people with severe addictions who stop taking them suddenly. Cocaine doesn’t have a withdrawal syndrome, for example. Most problem drinkers won’t go into DTs if they suddenly go on the wagon.

    There are non-psychoactive drugs that cause rebound symptoms if you stop taking them abruptly. For example, you can get rebound congestion from nasal sprays like Afrin.

    I think it’s reasonable to reassure consumers that antidepressants are non-addictive. The fear is that antidepressants are “happy pills” that induce euphoria and cause cravings. They just don’t.

  18. Thanks so much for bringing this up, PalMD! I’ve posted a bit of my own thoughts of the matter over at my place. We always learned about SSRI “withdrawal”, but then, when you’re in pharm research, you don’t really worry about whether or not your scientific terms are politically correct.

  19. I think as Kristan pointed out, the DSM used to conflate dependence and addiction, and this is probably why mental health professionals tried to avoid talking about “dependence” on antidepressants and talk about “discontinuation syndrome” instead of withdrawal. Depression is stigmatized enough without the added confusion of some people believing that a depressed person seeking sound medical treatment is equivalent to a drug addict. Wow, talk about kicking someone who’s down. Yes, health professionals know it isn’t true and are learning to use words more appropriately, but the average person watching the news, or the average journalist misreporting the news, does not see much difference between dependence, addiction, and substance abuse. Until the public is educated somewhat more, I would not make too much of an issue of “complete honesty”. Think of it not as evading the truth, but trying to use words in a way that gets people to see truth they might otherwise miss.

  20. Hmm. “Physical dependence” doesn’t seem like quite the same thing when there’s no psychological dependence.

    Discontinuation syndromes are common. Abruptly stopping lots of meds can provoke a period of readjustment. Stop clonidine and you’re blood pressure will go up. Stop a magnesium antacid and your poo will get hard. Stop Zyprexa and you’ll lose weight.

    Are all the above “physical dependence”?

  21. Anonymous

    The SSRI’s are great drugs when used appropriately and with informed consent. There are known physical symptoms associated with abrupt stoppage of these meds. The one exception may be fluoxitine (Prozac). It has a longer half-life and it’s levels decrease slowly when stopped.

    The SSRI’s, like vaccines, seem to be frequent targets of conspiracy theorists. Questionalble verbage in the PI becomes evidence of a massive cover-up in an effort to poison us. While the manufacturers likely downplay the dependance issue, SSRI’s are just drugs in a doctor’s toolkit to help patients. The doctor has to know what is right and educate the patient about the drug.

    Like vaccines, SSRI’s are given during emotionally vulnerable periods in the patients’ (parents’) lives. Doctors must be sensitive to this fact and take extra care to explain the side effects and how to stop the medicine when the time comes.

  22. To me, it seems that the ideal outcome of a drug is that you feel normal. I know my medical interventions are working because they fade completely into the background and I just feel like myself. That I may be physically dependent on them bothers me not one whit.

    To me, that dependence is different from addiction in that I don’t actively crave these drugs, I don’t feel high from taking them, and they actually improve my ability to think rationally and make good decisions. 😉

  23. CanadianChick

    I don’t have a problem at all with stating that something is non-addictive even though there are “side effects” associated with discontinuation.

    It’s certainly not just SSRIs that have discontinuation reactions that can be horrific…try stopping prednisone cold turkey on someone suffering extreme dermatological response to a nearly fatal allergic reaction. Yeah, it was fun for me, repeating the entire process except for the anaphylaxis.

    Addiction has a psychological component to it – at least it does in the colloquial. Problems associated with discontinuation? Not so much.

  24. I’ve been taking a fairly high dosage of Effexor XR for six years now. I’ve come to realize how lucky I am – after failed months on other antidepressants, Effexor was the one that actually worked. It’s a good thing too, because I fully expect to be taking it for the rest of my life.

    I had absolutely no idea when, as a teenager in treatment for anorexia, anxiety and depression, that Effexor was difficult to stop taking, even weaning the dosages carefully. No one even hinted that the drug had withdrawal effects. Maybe they told my parents, as I was a minor at the time, but certainly no one told me.

    I first learned how horrible the side-effects of discontinuation were when I ran out in college and couldn’t get my prescription refilled until the business week began. I have never felt worse, physically, in my life. The nausea, extreme dizziness, insomnia coupled with extreme fatigue, pain everywhere and general disorientation made me completely stop functioning. I just wanted to sleep, but I couldn’t. I knew I needed my Effexor dose, but I also knew I’d have to wait for two days. It was hell.

    This has happened twice more (and never again, thanks to 24/7 Walgreens near my new home) in the past several years, and both times were just as hellish. Two years ago I began seeing a new psychiatrist who matter-of-factly told me that she only prescribes low doses of Effexor as a last resort, given how hard it is to stop taking. She told me about a patient who was on the lowest dose (37.5) for about a year, wanted to stop taking it, and took over a year to quit – a painful, difficult year.

    Not everyone may be as sensitive as I am to the effects, but I’ve read hundreds of stories similar to mine. The worst part is that, when I went to the emergency room one weekend to get just a few pills to hold me over until I could fill my prescription, the staff was extremely skeptical about my detailed story and only gave me the dosage after five hours of grilling, insisting I get ahold of my rural doctor (who was on vacation!) who prescribed the meds, and treating me as if I was a junkie. They wouldn’t believe that the withdrawal effects were really physical and seemed convinced that I was either acting or deluded.

    I definitely know how physical (as opposed to psychological) these symptoms are, as I’ve occasionally forgotten to take a dose before bed and woken up feeling extremely miserable. There was no opportunity for me to notice that I hadn’t taken the meds until the phsyical symptoms kicked in. I wish that more people would speak out about this issue, as I can’t imagine how I could handle daily life trying to wean off Effexor, and if it *didn’t* work wonders for me, I could still be stuck with side effects and costs for a very long time trying to quit.

  25. Sarah,
    your story is not at all uncommon there are dozens of groups online of people who have this sort of radical reaction to withdrawal and the fact is even though “discontinuation syndrome” is recognized now, many years after it should have first been, in general docs still don’t realize how sensitive a significant minority is to withdrawal and so many people feel they must either stay on the drug simply because the withdrawal is so awful, or they go off much to quickly for their bodies and withstand awful suffering…I’ve met hundreds of people who have taken a year and more to get off an antidepressant…

    I’ve not met a doctor in real life (and I’ve been a psychiatric social worker so I know a lot of psychiatrists) who understands how serious an issue this can be…though I have now discussed the issue with a few competent docs I’ve met through the internet. And my own doc is respectful enough of my experience to listen to me, but had I followed his instructions I would have been toast. (this involves withdrawing from other psych meds that also have horrible withdrawal problems—but this fact has NOT been widely acknowledged by the medical community. At least now most people can find reliable info on antidepressant withdrawal, not so easy with other psychotropics.

  26. Interrobang

    At one point, my ex was on some kind of anti-anxiety drug (I forget which one; it’s been five years or so at this point), and his doctor abruptly refused to prescribe it anymore, and didn’t even bother to wean him off it slowly, the way the literature recommends. He had a seizure in Pearson Airport and broke his back from falling to the tile floor.

    Frankly, that was disgraceful on the part of the doctor, and my ex should have continued on the medication anyway. (If the doctors were so concerned about his dependence issues, they weren’t actually doing something about the several different opiate and opioid drugs to which he was actually addicted…)

    I’m kind of in the Perky Skeptic’s corner. At least as far as I’m concerned, I’m taking everything I’m taking because it all makes me feel normal, and if “normal” means managing a biological dependence, okay, fine. Ask me about my caffeine jones sometime, and why I can’t be bothered to quit.

  27. I think any terminology that leads to increased understanding is a good thing. PalMD- if you have a definition in your head for the experiences of “physical dependendence” or “addiction” that matches what patients may experience when they go off an antidepressant, I think it’s good to apply the accurate term. However, I do thing there is a good point in this: “Depression is stigmatized enough without the added confusion of some people believing that a depressed person seeking sound medical treatment is equivalent to a drug addict. Wow, talk about kicking someone who’s down.”… “addiction” to my (non-specialist) mind meant something much closer to what Sam C said… if my doctor had told me that an antidepressant was addictive, it might not have helped me understand what I was facing (and might even had made me feel more guilty about taking it, given stigmas and things).

    No substitues for clear communication with patients and followup, I suppose.

  28. Pharmacologically Enhancing Psychotropic Pharmaceuticals

    In the 1930s, physicians approached the mental illness of depression a bit differently that we do today. While acknowledging a likely cause of depression in one of their patients is often due to some great misfortune, they seemed to focus on what is called a complex. A complex is disturbances of ideas and impulses that are the cause of consistent habitual patterns of thought, feelings, and behavior. An example of this state of mind of one who is depressed is one who experiences an exaggerated or obsessive concern or fear. And the etiology for this mental disorder was often undefined. People react differently to life stressors in their life, so depression cannot be empirically determined.
    In the 1930s, psychotherapy such as cognitive therapy was recommended for treating the depressed patient, and not pharmacological therapy. Also considered for the depressed patient was positive lifestyle changes that would lessen the pain that the depression was causing them. Try and be grateful, they would tell their patient, as well as thankful and appreciative for whatever good may be in their life, and normally the depressed patient would eventually recover
    Times have changed since then.
    Presently, serotonin-enhancing drugs are the therapeutic regimens for those who are suspect of having a depressed state, or perhaps the patient simply asks for these types of drugs due to their perception that they are depressed. Furthermore, and remarkably, various other mood disorders one may have can be treated with these drugs, typically called SSRIs. What is remarkable is that the mood disorders which will be discussed later are subject to debate and have also been brought to the attention to so many others through disease awareness campaigns by the makers of these SSRI drugs. So mental flaws claimed to be relieved by SSRI drugs may not be the case at all.
    With depression, the most severe cognitive and behavioral malfunctions are expressed in what is called a major depressive disorder, which is also called clinical depression or major depression. Symptoms of this type of depression, which is the most concerning to health care providers in particular due to its severity, include decreased or flat affect, decreased interest in activities once enjoyable, self perceptions of worthiness, guilt, regret, helplessness, and hopeless by the sufferer, to name a few of the diagnostic features that may be present with one who has such a major depressive disorder. The disease has a vexing insistence on staying with the victim for a lengthy period of time- often continuing to progress symptomatically in severity and discomfort. This disease is very disabling, and cannot be lifted by one’s will, so all health care professionals likely agree that depression is a potentially serious condition with their patients. Suicidal ideation and attempts are associated with major depression.
    These SSRI drugs mentioned earlier are known by some health care providers as third generation anti-depressants. Such drugs, drugs that affect the mind, are called psychotropic medications. SSRIs also include a few drugs in this class that include the addition of a norepinephrine uptake inhibitor added to the SSRI in one capsule, and these drugs are referred to as SNRI medications. The combination of two different drugs has made them the top class of prescriptions for psychological misalignment.
    There are several available SSRIs presently, yet it is believed that only two SNRIs are available, which are Cymbalta and Effexor. Some consider these classes of meds, the serotonin enhancers in these medications, have been considered the next generation mood enhancers- after the benzodiazepine hype decades ago, which was followed by what were called trycyclic drugs for depression for some time. Furthermore, regarding SNRIs, adding the additional agent of norepinepherine is presumed to increase the effectiveness of SSRIs by some, yet not everyone claims relief from these types of drugs.
    Some Definitions:
    Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is known as the DSM, states that the definite etiology of depression remains a mystery and remains unknown with complete certainty. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected as a result of limited scientific evidence. In fact, diagnosing mental diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.
    Norepinepherine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med, as suggested earlier.
    And the depressive state of a patient certainly can be aggravated by another mood disorder at the same time with some patients. Anxiety usually exists with one who has a major depressive disorder. An objective diagnosis of such a mental condition is rather impossible to assess objectively. Therefore any diagnosis made for a mental abnormality lacks complete accuracy and assurance. Such illnesses can only be assessed conceptually, so the diagnosis or impression concluded by the patient’s health care provider is dependent on subjective criteria expressed by the suspected patient that is not mentally sound. At times, there have been screening programs that have been used for identifying depressed patients have proven to be largely ineffective. A social patient history is uncertain and tricky as well, some have said, yet is obtained often from such patients. There is no objective diagnostic testing for any mental malfunction to validate as to whether or not such a disease is present. A health care provider has to assess as to whether certain non-verbal or vocalized features are present with a patient in order to conclude confidently that one may have in fact some degree or level of depression. To assess a suspected depressed patient is further complicated by the fact that the exact cause of major depression is unknown. Research says that there is a strong genetic component to this illness.
    The diagnosis of depression as well as mood disorders that may exist within patients has increased quite a bit over the past few decades. Some have asked themselves, as well as others- actually how many people are really and actually depressed? What is believed is that if one determined to be cognitively impaired from a mental paradigm, then this may be in fact major depression. If this mental disorder is determined by a health care provider, it is possible that pharmacological therapy may be considered reasonable and necessary, as well as psychotherapy either suggested to be performed with or in place of medicinal therapy. Studies show that both therapies working together may be of most benefit for the depressive patient, yet it is not a guaranteed protocol for treatment in this way.
    It has been reported that around 10 percent of the U.S. population will at some point be affected by an episode of what may be a major depressive disorder. This is much greater in number than just a few decades ago. Perhaps media sources are to blame, by suggesting to their viewers that they may in fact be depressed. So the diagnosis and medicinal treatment have remarkably increased in a relatively short period of time in the United States. Of course, the expansion of those claimed and determined to be depressed does not sadden the makers of these drugs used to treat this mental disorder one bit, I’m sure.
    Some have said that so many more people seek treatment now for what they believe is a major depressive disorder they are experiencing, when in fact it may be possibly intense sadness, perhaps, due to a loss of some sort in their lives. There is a difference, and health care providers should have the appropriate tools and knowledge to discriminate between the two states of mental conditions. Sadness is not a medical problem. Symptoms associated with an unfavorable mental state need to be excessive and chronic to be considered to have in fact the medical problem of a major depressive disorder, as stated by others.
    In Time magazine’s June 16th 2008 cover story, it was reported that the military personnel in the Iraq war are pounding down SSRIs often. Every time there is a new war, there is a new drug, it seems. Yet the story may illustrate the frequent usage of these types of medications in a variety of different areas for different reasons. Some reasons may be valid and appropriate, yet others perhaps may not be reasonable for such medicinal therapy. However, as illustrated in this situation, they appear to be accepted as a treatment option without reservation.
    In regards to those pharmaceutical companies who make and market such psychotropic drugs in the manner that their manufacturers do is largely unknown to others, such as with screenings performed essentially by front groups, and so forth. However, what is known is that the psychiatry specialty, as they often treats and manages depressed patients, is the one specialty that receives the most monetary funding that is paid to them by these certain pharmaceutical companies for ultimately what they hope will be continued and additional support of the psychotropic meds that they currently promote to these doctors. Needless to say, the desire and the aspect of the pharmaceutical industry clearly is primarily concerned with encouraging as much use out of their products as possible- with both doctors and patients being the route of that increased use they desperately hope will occur.
    Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders that are suspected and determined by the health care providers who treat such patients. Yet these drugs discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related and suspected mental disease states, moods, or disorders. Patients should be aware of this fact as well as caregivers. And they may not be aware of the options available to them.
    For example, tens of millions of prescriptions are written by health care providers for these types of medications for their patients. These drugs are not inexpensive, either, as it is not unusual for a patient to pay greater than one hundred dollars to have their prescription filled for only a month’s worth of these particular drugs.
    Presently, there are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to be launched as a treatment for menopause.
    The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.
    Furthermore, these meds have received upon request of their makers to the FDA to have additional indications besides depression for these types of drugs they produce and market, and the indications they have received are for some really questionable conditions , such as social phobia and premenstrual syndrome. Also included with indications that now exist with these types of medications are the quite devastating conditions of what may be mild anxiety and shyness, yet the makers of these drugs consider such patients as having chronic anxiety with severe anxiety disorder, which others have said is rather obsurd. And it gets worse with the indications received for these types of drugs, which now include Obsessive-Compulsive Disorder, Panic Disorder, Agoraphobia, Post Traumatic Stress Disorder, Bulimia, and any form of stress disorders in general. I understand they are seeking indications for pain management as well with these SSRI or SRNI pharmaceuticals. Likely, they will get the indication for their drugs to treat such creative cognitive states apparently others have in great numbers.
    With some of these indications for these classes of drugs, I question as to whether or not they are actual and treatable disease states or medical problems. Yet with additional indications for particular drugs in these classes of medications, one can be assured that the market for these drugs will continue to grow- as more are prescribed to those patients who are progressively asking for them specifically for relief they anticipate they will receive from taking these drugs. What such patients are not aware of is that studies have shown that this class of medications is only effective in roughly half of those who take them. And some of the indications granted to drugs in these classes of medications may be considered disease mongering tacitly performed by the makers and marketers of these drugs to again grow the market share for particular drugs of this type. This is combined with drug companies who make these types of meds either forming or creating front groups in order to have more diagnosed with various medical problems that may not exist so their medication can be utilized more. And as mentioned earlier, such pharmaceutical companies have been known to either create or support front groups to ultimately encourage who may be normal people to get evaluated for the diseases indicated with these medications. Of course, such tactics implemented by such pharmaceutical companies are deceptive, inappropriate, unreasonable, unnecessary, and potentially if not actually dangerous to others.
    Perhaps of greater concern and danger with these particular psychotropic medications involve the adverse effects associated with these types of drugs, which include suicidal thoughts and actions, violence- including acts of homicide, and aggression- and this is only to name a few. Such events are devastating and have been demonstrated by those who have or are taking these types of drugs. It has been reported that the makers of such drugs are suspected to have known about these toxic and dangerous effects of their drugs and did not share them with the public in a timely and critical manner until forced to do so. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others for understandable reasons, which have included those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population of children, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, combined with the true decreased efficacy of SSRIs in general, which is believed to be only less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding of such important information- Elliot Spitzer specifically was the catalyst for this awareness, as I recall. Furthermore, that drug is in the spotlight once again years later. Some believe the drug maker knew about possible risk to the youth as early as 1991. Yet did not disclose such danger associated with their drug to the public or the FDA, and this was done with intent.
    And there are very serious questions about the use of SSRIs in children and adolescents regarding the possible damaging effects of these meds on them as they get older- these children and teenagers who are prescribed these drugs. Others are asking if this is really necessary- and are these drugs doing more harm than good for their children.
    For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect would possibly cause harm rather than benefit a patient on such a drug? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their self identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring within their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist, as demonstrated by others. It is observed in some who take such drugs, but not all who take these drugs. Yet health care providers possibly should be much more aware of these possibilities, possibly, along with the black box warning now on SSRI prescribing information for the youth that has existed since 1994. There are other medications health care providers could prescribe for such patients that have no less benefit for them then the serotonin drugs discussed.
    Finally, if SSRIs or SNRIs are discontinued by a patient rapidly, abruptly, and without medical supervision, withdrawals experienced by many of these patients are believed to be quite brutal that follow soon after this drug is not taken anymore by a former patient. This in itself may be a catalyst for one to consider or attempt suicide, others have suggested. Many are aware and understand that discontinuing these SSRIs and SSNIs leaves the brain in a state of neurochemical instability for some great length of time as the neurons need to recalibrate after existing in a brain over-saturated with serotonin and neuron alteration. This occurs to some degree with any psychotropic medication, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs and SNRIs, it is believed. And this seems to concern many, yet does not inhibit health care providers for continuing to select such therapy with these drugs for their patients.
    SSRIs and SRNIs have been claimed by doctors as well as patients to be extremely beneficial for the patient’s well -being regarding their apparent mental issues that resolve in time. Yet overall, the factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug that can harm themselves and others.
    Before these medications mentioned were developed, doctors praised trycyclics, another class of anti-depressants mentioned earlier, in a similar manner some time ago. Considering the lack of efficacy that has been demonstrated objectively with these new serotonin specific psychotropics, along with the deadly adverse events with these SSRI and SSNI meds only recently brought to the attention of others, other pharmacological and non- pharmacological treatment options should probably be considered, but that is up to the discretion of the prescriber. And the perception of the benefits derived by these types of drugs may be flawed, as there has been no decrease in incidences of suicide or remission of depression since these drugs have been available, many have concluded. Furthermore, recent studies have suggested that the supplement, St. John’s Wart, has shown to be as effective as medicine for major depression. Deficiencies in vitamins B12 and Folate have been suggested as a cause for depression as well. One study showed that a small jog performed by a depressed patient offered similar if not greater relief than a SSRI drug.
    It is my hope that such a prescriber rules out possible other etiologies for their patients’ mental conditions before they conclude that such a patient is suffering from true mental illness requiring the medications mentioned earlier, such as asking their patients about life stressors and other medications these patients have taken or are presently taking. Because at times, a doctor can in fact do harm without intent.
    “I use to care, but now I take a pill for that.” — Author unknown*
    Dan Abshear

    *Addendum to this article based on the following link recently discovered:

    There are greater than 60 symptoms associated with one who is or may be depressed, and there are different degrees of depression. The number of symptoms expressed by one who suffers from depression determines the severity of their depression.

    The characteristics associated with depression are affective, cognitive, and somatic.

    For example, affective symptoms are the core symptoms of a depressed mood, and the term that one has a flat affect is an indication that one may be suffering from depression. These symptoms may include sadness, dissatisfaction, crying episodes, irritability, as well as social withdrawal. It should be noted that many events could cause the expression of such symptoms besides depression in itself.

    Cognitive symptoms associated with depression may include pessimism, a sense of failure as well as guilt, suicidal ideation, and dislike of self.

    Somatic symptoms may include insomnia, fatigue, weight change, and loss of interests, such as sex or other activities engaged in historically with a depressed patient. It should be noted that stress can cause such symptoms as well, in my opinion.

    Recommended sites:

    Dan Abshear

  29. Ouch, I ran head-first into that Wall Of Text! Could we get an abstract, please? 🙂

  30. Robert S.

    Dan, if you think you have an article we should read, post a link. Copypasta of the full text make you look like a jerk or a noob. I assume you are simply used to writing articles rather then posting comment style. If you could please just post the link next time, with a simple reason why we should take a look, we will.

    In the grand tradition of the internet, TL;DR

  31. The court case Dan mentioned, involving Eliot Spitzer, is the main focus of Side Effects: A Prosecutor, a Whistleblower, and A Bestselling Antidepressant on Trial by Alison Bass. It was Rose Firestein’s idea to initiate the lawsuit — she was a lawyer who worked in the office of New York State attorney general Eliot Spitzer. Alison Bass is a former reporter with the Boston Globe; her credentials are excellent. The book was published in 2008.

  32. PennyBright

    I take Lexapro (escitalopram), and it’s been a lifesaver. I’ve gone through withdrawal from it twice now, and it sucks. And I’ve never heard anyone except my MD talk about ‘discontinuation syndrome’ – my shrink, and everyone on the psych ward when I was hospitalized, and every in my support group calls it withdrawal.

    I don’t think that it’s reasonable to say that I am addicted to my medication though. I can forget about the Lexapro – that’s what led to one of my withdrawal episodes – I was travelling, and just forgot to get my pill for a few days. From my understand of addiction, an addict can’t just forget about what it is they are addicted too.

  33. Exactly, PennyBright. I can forget about my oxcarbazepine, but I CANNOT FORGET ABOUT THE COFFEE!!!!

    She owns me, the coffee does.

  34. Andy,
    Thank you for telling my story.
    I’m very sorry that SaraH has to go through this experience.
    It’s amazing that physicians are not aware of this and don’t rely on patients’s words.
    SaraH, if you want to withdraw you have better change the XR version to tablets.
    Take a look at this site and you will have some withdrawal informations there.
    Some people don’t experience withdrawal but I’ve been searching since 2005 and have already seen many testimonies of people telling the withdrawal is hell.
    I’ve been there for 19 months.
    Unfortunately I didn’t know that the last phase was the hardest.
    When I was on 37,5 mg I started to feel worse and worse.
    I should have stay at this dose longer.
    Perhaps I would not have to go back to 150 mg due to terrible withdrawal symptoms after three months off EFFexor.
    Yes. At least that’s what my body and mind tells me when I miss a dose.

  35. Ana – thanks for the link. The site seems interesting, but it’s the kind of hyperbolic/conspiracy-theory style that I take with several grains of salt. I do feel that doctors and drug companies need to be much more forthcoming about withdrawal effects when they’re so serious. What happened to me in the emergency room, for example, should never happen to anyone on a drug that’s well-known for its withdrawal effects.

  36. SarahH, what information from that site do you find most hard to believe? In a previous comment I mentioned the book Side Effects by Alison Bass. Many of those claims you take with a grain of salt are written about by Alison Bass, a former reporter with the Boston Globe. Here’s one review of her book:

    “Alison Bass, a former medicine, science, and technology reporter at The Boston Globe, has put on trial in her book far more than just a bestselling antidepressant — she has used the case of Paxil to expose the unsavory and self-serving relationships among members of the pharmaceutical industry, psychiatrists, and members of the FDA. And she does it in a book that has the brio of a crime thriller… Bass’s riveting and well-researched account of these disturbing ties should be widely read by members of the medical profession, many of whom continue to believe, despite all evidence to the contrary, that they are immune to the influence of drug companies.”
    -New England Journal of Medicine

    For more reviews, visit But here’s another review:

    “Side Effects, by investigative journalist Alison Bass, grapples with the controversy over drugs used to treat depression, with a focus on Paxil, Prozac and Zoloft… Bass’ book humanizes the controversy in a way that makes the statistical arguments come alive. Because of her research and storytelling skills, a book exists that is both a public-policy primer and a compelling account of how seeming miracle cures are sometimes death sentences.”
    -USA Today

  37. Chelsea

    Hey guys I have some questions about antidepressants… I am currently 19 years old, the same age my mother was when she had her first psychotic breakdown. She was diagnosed with bipolar disorder… Now I am not sure if I too am bipolar, as I don’t seem to experience mania or too many highs and lows. I just feel low… all the time. This pit of depression is really starting to scare me. When I wake up in the morning, it’s immediately there. There is no 10 second morning bliss anymore, and these negative perceptions haunt me all throughout the day. The future seems so bleak and meaningless and hopeless and I cannot continue to live my life this way. I have become completely anti social. When I am around people, even those that I am very close to like my roommates, best friends, and my boyfriend, I feel like I have NOTHING to talk to them about. I don’t go out or do anything anymore in fear of having to face other people and the fear of having nothing to talk about with them. I feel like as time goes by, instead of growing and becoming more knowledgeable, I am becoming, well, basically stupid. My memory retention is HORRIBLE. I cannot rememeber names or dates or concepts that people were just talking to me about 5 seconds ago. It is very difficult for me to understand things because my mind is constantly occupied on my depression. This really scares me because I am so young and my memory is worse than my grandparents! I used to be the smart one all the way up until about 10th grade in highschool. Now, people are constantly proving whatever I say to be bogus, if I even have anything to say. I’m losing my friends to my depression; I know that my company is not enjoyable. I feel insecure, inferior to everyone, and tired all the time. I just want to hide in my bed all the time because that is the only escape from reality that I can find. I shake too! Constantly! And twitch! I am too embarassed to cuddle with my boyfriend because of the small twitches! Constantly worrying… I am really worried that I am not going to be able to handle and focus on school this semester. I am unmotivated and interested in nothing. I can’t even read a book because I forget the plot and the characters by the time I pick up the book again. I even forget movies…
    I have an appointment with a councelor at my university on tuesday. I know they will suggest that I get on antidepressants. Has anyone experienced similar symptoms? Will antidepressants improve my memory retention and my social anxiety? I always hear about people becoming “zoloft zombies”… Does it really detract from your personality? Please help, I am so scared and feel so alone…
    Thank you,

  38. I have an appointment with a councelor at my university on tuesday. I know they will suggest that I get on antidepressants.

    Strong work. They will probably be able to help. Other resources include:


  39. Chelsea, your story sounds familiar to me on a personal level. I think that people can tend to lose their confidence as they get older and lose their “youthful cockiness.” I can’t say if that applies to you or not. I remember in my early twenties a friend of mine and I were up talking about it late one night and he said, “it’s like I had balls, and then I lost ’em.” How confidence fits in is I think underplayed a lot of times, but I notice a huge tie-in to my confidence and depression.

    To talk about the “why’s” and causes is sometimes useless, but I state it so you can factor it in if you’re debating whether it’s runs in the family. Although even knowing if it runs in the family or not won’t help, because you’re depressed either way.

    I often feel low, and never have “invincible highs” associated with bipolar disorder. My moods can sway several times during the day, between severe and mild to moderate depression. One therapist I had suggested frequent mood swings such as that occur in those with borderline personality disorder, which he felt I have to some degree.

    My mood swings are most often triggered by external events and how I react to things. Minor events can upset me greatly. Often it’s not an event but how a person reacts that depression or anxiety will result. For instance, if a person loses all their money, they can react like it’s the end of the world, or they can treat it as an obstacle to overcome, be grateful they’re still alive and can learn from their experience. (That’s an extreme example, most people will not handle losing all their money with optimism.)

    I tend to think if your boyfriend loves you he won’t mind you twitching if you cuddle. Most loving partners are understanding of minor things like that, and hopefully they’d try to be supportive and ask what’s wrong, or offer whatever help they could. I typically shy away from offering advice on relationships, however, so I’ll stop there.

    If you’re interested to read about other people’s experience with depession, or specific medication, I recommend Google Blog search at It’s easier to get a wider variety of opinions and personal experiences from blogs than from typical search engine results.

    Many of the newer antidpressant drugs like Zoloft, other SSRIs and SSNIs have warning issued that the risk of suicidal thoughts is increased in patients up to 25 years old. From the patient medication guide for Pristiq (Effexor’s cousin):

    1. Antidepressant medicines may increase suicidal thoughts or actions in some
    children, teenagers, and young adults within the first few months of treatment.


    Antidepressant drugs increased the risk of suicidal thinking and behavior in studies of children, adolescents, and young adults (ages 18-24) with major depressive disorder (MDD) and other psychiatric disorders. No increased risk has been shown for adults over age 24, and the risk decreased for those aged 65 and older.

    So if you decide to go on any medication, look for a doctor who encourages close monitoring the first few months. Many will schedule your appoint six weeks apart, in my experience, but if that happens, make sure you have easy access to your doctor or a nurse while you are starting medication.

    If it’s not too severe and you don’t feel like you’re going to commit suicide, there are many other ways to cope with depression, and a google search should be helpful there. They include reading, exercising, meditation, keeping social contact with friends and family (I know it’s very hard sometimes), and venting on blogs, if writing is your thing. 🙂

    This is all just one man’s opinion, so do your research, or if you feel desperate, schedule an appointment with your doctor.

    Oh, I almost forget, you can find many resources, if you need them, including information about suicide hotlines at Psych Central, and forums where people discuss issues similar to yours. Another place you might find answers to your questions. Good luck and take care.

  40. Chelsea, I cannot tell you how GLAD I am to hear you’re getting help.

    I went a whopping thirty-seven years before my bipolar disorder was diagnosed! Getting on medications has literally been the BEST thing that has ever happened to me! It has not detracted from my personality (as anyone who sees my abuse of the capslock key and the exclamation points can attest) and words cannot describe how much my life has improved now that those HORRIBLE depressions are gone!

    I still get sad sometimes– but normal sadness, that passes, like normal folks feel, as opposed to the CRUSHING BLACK VOID that depression is. Suicidal ideation was so normal a part of my depressions that I didn’t even notice I was doing it, really.

    This is anecdotal, based on the experience of myself and another friend, but sometimes people with bipolar disorder need antidepressants just to get the mood cycling to manifest at a diagnosable level. My friend explained it as, “Before, my mood cycles were way down here, then I got on an antidepressant and the cycles moved up here where you could see them!” My psychiatrist prescribed me an antidepressant for in the morning and a mood stabilizer for taking at night (the timing is to minimize possible interactions between them).

    I’m going on about this so vigorously because I too used to really be scared about going on any kind of antidepressants. I thought it would be suppressing an essential part of me, or make me unable to do art anymore. In fact, what my meds do is let me LIVE my life, finally!!! I will happily take them for the rest of my life and be thrilled about feeling myself, not living as a slave to that same depression that plagued me throughout my life.

  41. Depression is a serious life-threatening illness. In 2005 it was the 11th leading cause of death and killed 32,637 (National Vital Statistics Reports, Volume 56, Number 10, April 24, 2008). Homicide was 15th and only killed 18,124.

    Serious illnesses require serious treatments which may have serious side effects and still be acceptable. What is necessary is to balance the side effects with the therapeutic effects. Every drug has side effects. Virtually every drug has withdrawal symptoms. When I stop drinking coffee I get really bad headaches. Is that addiction or discontinuation syndrome? When I don’t breathe for a while I get really bad oxygen discontinuation syndrome.

    Every drug is unique, as is each person who takes it. The interaction of those two unique things is itself unique.

    I have been depressed my entire life. I have a very distinct memory of asking my mother if I could kill myself when I was about 8 years old. At the time I was being badly abused by my older brothers (5, 4, and 3 years older than me). I have PTSD from that abuse many decades later; have been in therapy with senior clinicians (only 2) for decades. I have been on multiple meds, imipramine, nardil, desipramine, Prozac, Zoloft, Amoxapine, serzone and perhaps some more. What initially worked the “best” for me was a combination of Zoloft (100 mg twice a day), Amoxapine (37.5 mg once per day) and Serzone (I think 100 mg once per day). It was only after I was on these meds (at ~40) that I realized how depressed I had been my entire life. I actually started looking forward to having time to do things.

    That was all before I raised my NO level about 6 years ago. Now I am down to taking 100 mg of Zoloft once per day and have never felt better. My experience with depression and how my physiology has changed since I increased my NO level has been quite informative in understanding NO physiology. Whether I am “addicted” to Zoloft, or merely physically dependent is so far down my list of what is important that it doesn’t register. I have too many things that are actually important to me that I want to do to spend time thinking about that.

    I see depression as the necessary aversive state between a “normal” metabolic state and the euphoric near death state that physiology invokes when one is running from a bear. That state must be euphoric so that one can run despite pain and injuries. That state actually allows one to run oneself to death and feel good doing it. That is the source of the “runner’s high”. Evolution has configured our physiology to invoke that state for such emergencies as running from a bear where to stop and rest is to be caught and die. Physiology disables the normal safety features of pain and fatigue so that one can run oneself to death. This is not a state that is safe to invoke willy-nilly. But because it is euphoric, there is a strong compulsion to be in that state if it could be easily invoked. That is where depression comes in. Depression is the aversive state that physiology has to go through to get to the euphoric state.

    The euphoric state can be invoked in a heart beat if a bear crashed through your door. I think the stimulant drugs of abuse invoke the euphoric state too, and that is why they have serious side effects from prolonged use. There is no “emergency” power source that comes on line in a metabolic emergency, what physiology does is turn off normal basal physiological functions that are less important than running from the bear. Things like healing, growth, repair, disposal of damaged proteins. Anything that takes longer than escape from the bear isn’t needed until after you have escaped, so it can be turned off. Turn off everything else and your running can go to 11.

    But turn those things off for too long, and there is irreversible deterioration. I think that is what causes the degeneration of stimulant abuse. I think that is what causes the degeneration of the manic state. I think that is what causes the degeneration of chronic stress.

    A lot of the bias against antidepressants is by people who have never been depressed and have no clue what it is actually like. It is a form of bullying; an attempt to deny effective treatment to people who are depressed so that the depressed person is easier to bully and exploit. This is why scientologists are so against it. Depressed people are much easier to lure into their cult and exploit.

  42. Correction for my comment above:


    A lot of the bias against antidepressants is by people who have never been depressed and have no clue what it is actually like.

    Based on that statement, it’s clear you didn’t read much, if any, of the discussion on this page. It includes comments from people who are “biased” against medication.

  43. babayaga

    I have no idea what my URL is or how to get a Typekey ID please help as I want to contribute

  44. LanceR, JSG

    TypeKey is optional. URL is any URL you want to put in. It’s also optional.

    All you really need is a name (babayaga works) and a valid email address (for authentication purposes.)

    You are good to go!

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