I am more than a dozen clicks deep into the wave. “They will say that you are sick so they can harm you… The truth is people are severely oppressed and they don’t know it…” – I scroll a little further – “There is no such thing as mental illness or developing a fictitious mental illness or disorder. Prescribing neurotoxins is called attempted negligent homicide.” Global government is trying to kill us, I think these people are saying, with what have become problematically known as “happy pills”. All in all, not the worst way to go, I think to myself, briefly.
I started a long way from here, above ground, with one clear question in mind: in 2019, are antidepressants no longer fit for purpose? As a growing tide of both professional and public voices question the efficacy of SSRIs (selective serotonin reuptake inhibitors), discussion on the subject is becoming increasingly contentious. Concerns are being raised: can you become dependent on them? Are we being given the right information about side-effects? Do they save lives, or actually work at all? Are SSRIs, as some claim, responsible for violent behaviour, such as mass shootings, or increases in suicide rates among young people? Are we really being held captive by Big Pharma profiteers, or is it all empty – and dangerous – conspiracy; scaremongering that might only serve to instill fear in already poorly people?
Against a back-drop of record numbers of people taking SSRIs – 70.9 million prescriptions for antidepressants were given out in 2018 in England, compared to 36 million ten years earlier – there’s significance to these questions. Only, it’s not easy to find clear answers. Frequent media reports are conflicting and often err on the provocative or salacious – take, for instance, reports from just this week which range from asking whether antidepressants are addictive to warnings about increased risk of gestational diabetes, to statements that “GPs are leaving thousands in the dark” about side-effects. Meanwhile the internet is a pandora’s box all of its own. It’s noisy and complicated and, during the desperation of depression and/or anxiety, quite frightening.
To be clear, I have a vested interest in this subject. Until recently, over the last two years I’ve taken SSRIs as part of my daily routine and as a treatment for depression. In 2017 I went to see my GP when things were already too bad and was prescribed 80mg of Propranolol to stop my chest constricting in fear and 20mg of fluoxetine, more commonly known as Prozac, which was soon increased to 40mg and, later, 60mg. I came into depression with a quiet mistrust of drugs like these, largely based, I think, on the ideological debate – and stigma – lingering over them.
I don’t remember having a conversation about the possible side-effects of the drugs I was prescribed (I don’t remember much about that period of time at all, being honest). For the first couple of weeks on Prozac I felt no different and stayed stationary on the sofa, as I had been for weeks before then. Then one day, when my housemates went to work, I got up and made a cake (I hadn’t for years before and never since). I started to be able, slowly, to eat again. But as my tears dried up other symptoms began. I started to get intensely itchy skin, restless legs, a tight jaw, constantly grinding teeth and horrifying lucid dreams. I felt slightly better than before, but there were side effects. Just under a year later, I was weaned off Prozac and prescribed 20mg of Citalopram, followed by 40mg.
Antidepressants have been in use since the 1950s, when they were prescribed to treat “melancholia”, or “nerves”. Back then, tricyclic antidepressants were prescribed, but reserved for severe cases – mainly because the pills not only caused severe drowsiness and weight gain as side effects, but also because they could be lethal in overdose. Giving them to suicidal people, then, was quite a risk.
SSRIs were first approved for use in the late 1980s, starting with Prozac which was discovered by accident by psychiatrists looking for alternative treatments for schizophrenia and became a prototype for developments in the following decade. It was sold on the idea that illnesses like depression are caused by a “chemical imbalance” in our brains, that these pills could fix. They had less side effects, physicians were told, than other attempts to medicate despair. By the late nineties the drug was a household name, a “cult” prescription of sorts, and by 2004, traces of Prozac were reportedly found in British tap water.
It doesn’t seem unfair to say that Prozac’s popularity was rooted in its success. People seemed to respond in a largely positive way to the drugs – and to the idea that upturned brain chemistry was the root of sadness, and that there was a solution to this. Some psychiatrists wrote books claiming that SSRIs made their patients suffering from major depression “better than well” – and for many people back then, now, and for the time in between, SSRIs have undoubtedly helped. The thing is that there is little information about how, or why. And so, even by the end of the late nineties, doubts were forming about their effectiveness, purpose and prominence within society. Controversial studies claimed that the therapeutic benefits of SSRIs were no more sophisticated than the placebo effect. Factions began forming which, in some pockets of society, quickly turned to opposition.
One of those opposers, now in her sixties, was Ann Blake Tracy. In 1994 she authored Prozac: Panacea or Pandora? The Rest of the Story on the New Class of Ssri Antidepressants Prozac, Zoloft, Paxil, Lovan, Luvox & More (capitalisation her own) and the head of the International Coalition for Drug Awareness, which she set up. Tracy believes that psychiatric drugs are a “prescription for violence” and assigns abhorrent and widespread crime in America to SSRI use. And she has quite a following. She’s quoted in the LA Times in a piece titled “Go off drugs, lose control?” and she has, in the past, testified to the FDA as an “expert witness”. (Though it should be noted that just because something has been reported to the FDA does not mean that there is scientific evidence for it.)
The first thing I ask her – and the first thing you should probably know about Tracy – is where she trained. “Actually I didn’t,” she replies. “I just started researching like crazy.” I notice that in videos of her testifying to the FDA and on some websites she is credited with a PhD, but she doesn’t tell me about this. The only thing I can find about her qualifications is a letter purportedly from George Wythe University in Utah alleging that her degree is not recognised as it was never previously listed; that no coursework or doctoral level work was completed.
We speak for two hours, during which time she tells me 17 stories that begin with SSRIs and end a little bit like this example: “A woman in my neighbourhood was getting her three children ready for church and stabbed all three of them. She chased them through the house attacking them with a hammer and a sheep-shearing knife and killed all three and then herself, by stabbing herself twice in the heart.
“She was trying to get off Prozac,” Tracy adds. “The police blamed her husband who was out back working in the garage while it happened and came in to find it. But the whole family had said that she was definitely psychotic.”
Tracy is one voice in what appears to be a far-right movement that blames SSRIs for mass-shootings in the US, though there is no scientifically meaningful link. Other theories that Tracy poses to me are that mixing SSRIs with alcohol makes people “psychotic” (it’s not advised, of course, because alcohol is a depressant but most research says that this cocktail is likely to make the user more sedate); that SSRIs cause REM sleep disorder (some research appears to confirm this, but not the anecdotal, extreme violence she equates with the condition); that the reason “spirituality” is being lost among the public is because “Christian women are the biggest users” of antidepressant drugs. I can’t find any evidence for this claim. In 2006, Tracy apparently testified to the FDA that, because of SSRIs, “Child sex abuse has increased dramatically with even female teachers going manic on these drugs and seducing students.” I can’t find any evidence for this, either.
Tracy says that her proof for these claims is based on a catalogue of 5000 news reports which she has collated on her website and via court cases she regularly cites. She claims that she knows what psychiatrists and other experts don’t because “no one bothers to read the research”. When I point out that there are literally millions upon millions of people on SSRIs who are not performing violent or sexually deviant acts at anyone time, she tells me that’s because God has blessed us (so far). “I tell [people] to go out and read court transcripts so that [they’re] getting the kind of evidence a jury is getting because you’re not going to get it anywhere else,” she says, confusingly. She adds: “Except for my book.”
Ultimately, she believes that SSRIs and our use of them are the product of government and pharmaceutical conspiracy – a well-worn idea that pretty much sounds like the plot of a dystopian psychological thriller. It appears to be at the extreme end of the rising anti-antidepressant movement, where doctors and nurses are demonised and in cahoots with global government, where Big Pharma is always watching and thousands of “truth-seekers” post existential questions like, “why don’t psychiatrists take psychotropic drugs???” in sinister black and red typeface on Facebook.
Just like other Big Pharma conspiracies (for instance, a belief that a cure for cancer has been found – but not revealed – to maintain a profit from treatment), it works on distrust of the powerful and circular logic: missing research to back up theorists’ claims becomes further evidence to support the “cover-up”. It’s all very emotionally highly-charged and the hyperbole of it all makes me wince. Still, it’s not surprising.
It’s not surprising that many people are drawn to the familiar, simple narrative of extreme conspiracy; of goodies and baddies, “us” and “them”, people vs power, because it’s a reflection of our fractured political climate. And conversely, it’s near-impossible to navigate the complex world of psychiatry and mental health science: the more information I read the less informed I feel. It’s hard to know what and who to trust.
There is credence to the idea that pharmaceutical companies have inordinate power over us. Medicines cost the NHS around £7billion per year – it’s the third most profitable sector after finance and tourism. Pharmaceuticals is the largest market in the United States. Public health care, like everything else, is a capitalist venture. Moreover, there is an entire movement within the psychiatry profession itself which throws question marks at the dominant role of the pharma, and even the system of categorisation of mental health issues itself.
“Big Pharma is very clever with marketing,” says David Healy, a professor of psychiatry at Bangor University, psychiatrist, psychopharmacologist and author of Pharmageddon. “We want something that is just going to solve life’s problems. So Big Pharma play on our desires. It’s like the pornography industry, they don’t create the desires. But they play out those desires.
“In the case of SSRIs, there’s actually nothing that shows an SSRI is highly effective, at least not for depression. They are slightly better for conditions like OCD, but the reason that they’re on the market for depression is because the companies thought that is where the money is.
“If you want to know about what SSRIs are most effective for, it’s men who have premature ejaculation. But you don’t hear about that. Because at the time SSRIs came about that was a very small market.”
Prof. Healy has written extensively about his own concerns regarding the pharmaceuticalization of medicine. He has been vocal in criticising the lack of transparency in drug trials and the practice of “ghostwriting” (doctors and scientists who put their names to medical research they haven’t conducted within the medical profession) which has long been an issue of contention in psychiatry over claims of skewed or biased data. This was infamously exposed via a US trial carried out in the nineties, which sought information on the efficacy of paroxetine, an SSRI, in treating 12 – 18-year-olds diagnosed with major depressive disorder. The positive outcome, Study 329, was later found to be ghostwritten by a PR firm hired by British pharmaceutical company SmithKline Beecham – a revelation that was reported to have “changed medicine”. The report made inappropriate claims about the drug’s efficacy and downplayed safety concerns.
It doesn’t sound particularly encouraging. Alarming, even, because, to use Healy’s words, “you can’t make the guidelines if you don’t have the data”. There’s a chance, then that the NICE guidelines – evidence-based recommendations for health and care in England – might be using the wrong information, not only about antidepressant drugs. It also shows that Big Pharma is a legitimate part of the conversation, though to what extent is up for debate. But pharmaceutical power struggles are not the only reason that some are questioning the role of SSRIs.
Healy claims to be the “first to draw attention to the now well-publicised suicide-inducing side effects of many anti-depressants.” He also tells me there is evidence to suggest that SSRIs could make some people violent, that side effects like genital numbness and the inability to have sex are pervasive and upsetting. I experienced this – I couldn’t orgasm for the entire time I was on Prozac – and it wasn’t exactly pleasant. But it was a lot better than feeling like I wanted to die, I tell him.
One of the main issues for Healy, however, is that withdrawal is often so difficult that patients begin to feel that it’s the pills keeping them alive. “It used to be, back in the 1960s and 1970s that if you were severely depressed you’d probably get three months’ worth of antidepressants – a bit like a course of antibiotics,” Healy says. “Now you’re told that you might need them for life, like needing insulin. And if you begin to feel nervous when you try to come off them, this proves to you that you need them.
“Not unreasonably, people believe that the pills saved their lives, but they don’t realise that actually SSRIs have become part of the problem.”
It makes me feel a bit stupid to hear this. I’ve often said to friends and family that, along with their support, it was drugs that saved me from disintegrating entirely. SSRIs allowed me to function just enough to start to think about getting more structured help (Cognitive Behavioural Therapy ) and to try and interact, just a little, with the world again.
When I started a long process of withdrawing from Citalopram at the beginning of the summer, I felt my core shift in that frightening way again – the unease, the crawling skin and thick black thoughts. It felt like I was slipping again, but I was determined to see what I was like without medication, two years after I first tumbled. I thought it might be a relapse but, according to Healy, withdrawal symptoms mimic the condition. I can wholly understand why people choose to just keep taking the drugs rather than experience those feelings again.
“We don’t know enough about withdrawal,” says Professor Gwen Adshead, a forensic psychotherapist and visiting professor at Gresham College and Yale School of Law and Psychiatry. She makes it clear that it is a “very bad idea” to stop any medication abruptly: “If you want to stop taking something that is fine, but you’ll need professional guidance to tail them off over a lengthy period and think about how you’re going to get some psychological support to manage your mood in the future.
“Until very recently, we didn’t have evidence that some people – not everyone – can become dependent on them (such that they have withdrawal effects if the medication is stopped) particularly if a medication is stopped abruptly. But that’s not to say that we shouldn’t be taking them in the first place.”
Adshead doesn’t agree with Professor Healy that “SSRIs make you suicidal”. She’s also gently skeptical of ideas held by him about Big Pharma and violent behaviours induced by antidepressants. “I wouldn’t want to rubbish the possibility that antidepressants could, in some vulnerable individuals, make them more impulsive,” she says, “But I would just say for the record that when it comes to acts of violence, you never get a single cause. Never, never, never. It’s always multiply-determined.”
As for Big Pharma, she says that it’s “unwise” to be too conspiratory. While there is always a purpose for critical debate on this subject, Adshead notes there are over-arching, global trends at play which could be fuelling this narrative. “Human life is more cock-up than conspiracy much of the time,” she says.
“I do think it’s interesting that there has been more of a challenge to the idea of scientific method providing a reliable knowledge base. It’s a very particular 21st century fashion – previously the tension was between organised religion and science, but now it’s between science and a group of people who say ‘I don’t believe there’s such a thing as expert knowledge’. Anybody’s view is as good as anybody else’s.
“To me it’s saying ‘I pitch my crude simplicity against your informed complexity’. When you’ve got a world leader who makes it clear he has no respect for the truth, those people are legitimised.” A week after we spoke, Donald Trump groundlessly claimed that the pharmaceutical industry is driving calls for an impeachment inquiry.
Increasingly as I head under the wave of existential and ideological debate, I seem to move further away from clear answers. The gargantuan issue throughout all of discussion about antidepressants – about their efficacy, their widespread use, their side-effects and withdrawal effects – is that we just do not know enough. Are antidepressants fit for purpose? I don’t know. Do psychiatrists know for sure? It seems not. Are GPs equipped with the right information and services to prescribe efficient treatments for depression? I don’t think so. Are SSRIs often used as a scapegoat for wider political and social issues, like gun-violence? Yes.
I don’t think that I was duped by Big Pharma when I was prescribed and took antidepressants, but I do think that Big Pharma exploits a vulnerable gap in the system that urgently needs addressing. SSRIs have their place in mental health care, at least until there’s solid proof of why they shouldn’t, but the levels of prescribing aren’t reflective of their efficiency, and that’s a problem.
There needs to be more options – especially as the gaps in knowledge about these drugs are addressed. Psychotherapy and other psychological support does not receive the same interrogation or media as SSRIs. It should be just as scandalous that this is so hard to come by from our health service, as the stats showing increasing antidepressant use are. “From my perspective it’s not so much Big Pharma pushing SSRIs but a much simpler issue that GPs in particular, and psychiatrists too, don’t know what to do with the people who come to them,” Adshead says. “They feel they have to do something in that tiny, ten-minute window, so they give a prescription in the absence of other crucial psychological support services.”
More than that, we need more information. While there’s understandable dissent within psychiatry itself – and much useful debate – for the public it’s overwhelmingly unclear. It makes it very easy for misinformation to spread unchallenged.
Are antidepressants still fit for purpose? The answer is still up for debate.