If you are depressed or anxious, and are considering getting some help or treatment including starting antidepressants, a sensible way to proceed is to ask yourself a series of questions about your experiences and circumstances. To help you, here are some important questions to ask yourself, either alone or with a friend, a relative or a doctor, and some factors to consider in each case:
Do I need or want any treatment at all?
Most cases of depression and anxiety are mild, and most will resolve with time – as people say, time is a great healer. The diagnostic manual of US psychiatry, the DSM-5, states that recovery from major depression begins within three months for 40 per cent of people and within a year for 80 per cent of people.
If there is a particular trigger for your chronic feelings of sadness, such as a stressful life event, you might be better off focusing your efforts on getting relevant practical help, such as extra educational, financial or housing support. Similarly, relationship problems might be best addressed by some form of couples therapy. One tell-tale sign that your main problem is stressful circumstances and not depression per se is to think about whether you are preoccupied by the stressful situation rather than with any symptoms related to depression or anxiety.
Having said that, when the stress of life circumstances feels overwhelming, antidepressants can still offer valuable help by providing you with much-needed relief from depression-related symptoms such as insomnia and fatigue. This is particularly true if you have a history of depression that needed antidepressants before, or if the symptoms persist.
Would I be better off with a talking therapy?
Mild to moderate depression and anxiety are often best treated with cognitive behavioural therapy (CBT) or some other evidence-based, structured psychotherapy, such as interpersonal therapy (IPT). CBT tends to focus on ways to address patterns of negative thinking, whereas IPT focuses more on difficulties you might be having with other people. Indeed, in England in 2021, the National Institute for Health and Care Excellence, which provides independent, evidence-based guidance to the government, issued a renewed draft guideline for treating depression in adults, which stressed that talking-based treatments should be the first choice for addressing mild to moderate depression.
The problem is finding a trained therapist with the time to treat you. In Edinburgh in Scotland where I work, and where services are relatively good by international standards, there are only a small number of clinical psychologists, nurses or other health professionals who are trained to provide CBT or IPT. Clearly, they could not treat all the estimated 50,000 people with depression/anxiety each year (of a population of roughly 500,000) who might benefit. In fact, each typically treats 10-20 people a week for about 3-6 months – ie, a maximum of about 100 people a year.
Wherever you live in the world, the chances are high that, if you are seeking psychotherapy for mild to moderate depression, you will likely have to find private psychotherapy, if you can afford it. In my experience, most private therapists provide counselling, or what might best be called generic or supportive psychotherapy, often with a psychodynamic orientation. This can still help, especially in those who cannot engage with CBT, but arguably most of the benefit comes from non-specific factors such as ‘a problem shared is a problem halved’, general support, and the inculcation of hope. In my experience, they are less likely to offer structured psychotherapies, such as CBT and IPT, which have been shown in multiple clinical trials to have benefits over these non-specific therapeutic factors, as have antidepressants.
There is some evidence that CBT or IPT may provide some greater longer-term benefits than antidepressants. This isn’t surprising if one considers that these approaches give people ways of dealing with depression or anxiety that they can invoke again if they need to. However, it is important not to overstate the reach and benefits of psychotherapy. For instance, my patients with severe depression often find that the effects of psychotherapy tend to fade over time and that they require top-up or ‘booster’ sessions or perhaps a whole new course of therapy.
This ongoing desire for therapy flies in the face of the common (mis)perception that psychotherapy somehow gets to the ‘root of the problem’ of depression in a way that drug treatments cannot. Perhaps this same sentiment feeds the harmful myth that taking antidepressants is ‘the wimp’s way out’ because the person is not facing up to their problems. It’s true that there can be historical roots to many people’s depression, such as childhood sexual or physical abuse, but psychotherapy usually helps rather than ‘cures’ these issues. Psychotherapy can be helpful for those with moderate to severe depression, but that may depend on a high level of therapist experience and expertise.
You should also bear in mind that 30-40 per cent of people do not benefit from psychotherapy, which is about the same as the proportion of patients for whom antidepressants do not help (but, fortunately, most people respond to one or the other or both). And, as with any intervention, talking treatments can do harm as well as good. This is a neglected area of psychotherapy research but, for some perspective, consider data from a recent study of hundreds of people who received therapy for depression or anxiety via the NHS in England, which found that just over 14 per cent of clients reported that they had been made worse in the long term. The risk of harm has long been recognised in the psychodynamic community. Simply put, there are some unfortunate people who have been too damaged by traumatic upbringings to be able to tolerate, let alone benefit from, talking about it. A previous Psyche Guide takes you through the different therapists available and what to discuss in your first session to maximise the chances of a positive outcome.
So, when should I take an antidepressant?
If your depression or anxiety is mild to moderate, and if time and a talking treatment have not helped, and especially if things are getting worse, then you should consider taking an antidepressant. Moreover, if your depression or anxiety is moderate to severe, you should consider taking an antidepressant combined with CBT as your first form of treatment.
This raises the question: how do you know if you are moderately or severely depressed? You could count your symptoms from the acronym in the Need to Know section above, though this is best done by a trained clinician. Or you could fill in a free questionnaire, such as this patient health questionnaire (while this too is designed to be administered by professionals, you can still score it yourself).
In general, the more depressed you are, the more likely you are to benefit from antidepressants. Other markers of a more severe depression include a complete lack of pleasure, feeling emotionally numb or ‘cut off’, agitated, or being markedly slower than usual in your thoughts and movements. I was taught that if a person has the so-called biological or melancholic features of depression – such as disturbances in sleep or appetite, and especially waking early in the morning and feeling at your worst early in the day – then antidepressants are more likely to help. This is a useful rule of thumb, but caution is required because the research evidence for these associations is sparse.
Obviously, if you are too ill to be able to think clearly and comply with the demands of psychotherapy, or would simply prefer an antidepressant, then these are more reasons why you should take one.
Yet another consideration is if you need or want to get better quickly – for example, this might be the case if a person is feeling suicidal, or if their depression is causing urgent employment or relationship issues. Psychotherapy can sometimes work relatively quickly but it tends to take months for a meaningful benefit, whereas antidepressants usually lead to a significant beneficial response in weeks.
Which antidepressant should I take?
This is a decision you need to make carefully with your doctor. However, it might be helpful to go into these discussions with some basic background information on the various options, provided below. Worth remembering is that all the antidepressants that are currently licensed for depression or anxiety have been shown in clinical trials to help more people get better than an inert placebo pill.
The drugs that current evidence suggests are the most effective for depression are the older drugs, such as amitriptyline (a so-called ‘tricyclic’ based on its chemical structure) and escitalopram and paroxetine (known as ‘selective serotonin reuptake inhibitors’, or SSRIs, based on their chemical effects in the brain); and newer drugs, such as mirtazapine (known as an ‘atypical antidepressant’ because it works differently than most others) and venlafaxine (a ‘serotonin-norepinephrine reuptake inhibitor’, or SNRI, again based on its chemical effects in the brain). Other SSRIs, such fluoxetine and sertraline, are slightly less effective, but also tend to cause fewer side-effects.
For anxiety, duloxetine and venlafaxine (both SNRIs) and escitalopram (an SSRI) are all similarly efficacious, and most people take them without problems. Other options, including mirtazapine, sertraline and fluoxetine, cause few problems and are also effective, although these findings are limited by smaller sample sizes. The sedative antipsychotic drug quetiapine can also be helpful for anxiety and depression, but weight gain can be a problem.
What adverse effects should I expect?
You’ll have noticed I already referred to side-effects or problems a few times. There are many potential side-effects of antidepressants, but most are rare. Some, however, are classed as ‘very common’ (affecting more than 10 per cent of people who take them) or ‘common’ (impacting 1-10 per cent of people). Because of this, people prescribed antidepressants should receive regular medical review, especially in the early stages of treatment, to check that they are not feeling worse on the drugs.
For the SSRIs, these common side-effects include reduced appetite, nausea, ‘tummy upset’ and sexual dysfunction that many, but not most, of the patients I have treated over 30 years told me they have suffered from. My experience is that most people find these problems are usually mild and tend to fade away after the first couple of weeks. SSRIs can also make you feel agitated or ‘wired’ when first consumed, which is why they are usually best taken in the morning with food.
I have found that forewarning patients of these common adverse effects and how to deal with them helps my patients to tolerate the drugs – and perhaps even increases their effectiveness! I suspect, but do not know, that people think I am a better doctor if I tell them what will happen in the first couple of weeks and then it does. If I also tell them, as I typically do, that they are likely to feel better in 2-4 weeks, then perhaps that is also more likely to occur. One could think of this as part of the placebo response, but I think it is one of the non-specific elements of treatment that is part of being a good doctor or therapist, which includes sharing problems and inculcating hope. I also tell my patients with depression and/or anxiety that they will get better, that it is just a matter of time and finding the right treatment – and, thankfully, nearly all of them do recover.
The side-effects profile is quite different for so-called ‘sedative antidepressants’, such as mirtazapine and duloxetine, amitriptyline and clomipramine, which can cause sleepiness. Sedation can actually be a good thing if you are struggling to sleep; if, however, you are left feeling ‘hungover’ the following day, the dose can usually be split into 6pm and 10pm doses to be tolerable, which is an option worth discussing with your doctor. Less easy to deal with is that these sedative antidepressant drugs also tend to increase your desire for ‘fizzy pop’, biscuits, cakes and sweets. However, this is usually manageable if you drink water and eat fruit instead, dull as that may sound.
Will antidepressants interfere with therapy?
Far from it – there is strong evidence from clinical trials that both drug and talking treatments work better when they are combined than either does alone. Although that evidence is for CBT and IPT in particular, I suspect that the general principle holds for all combinations of pharmacological therapy and psychotherapy.
When you think about it, this is not that surprising – even to be expected. Psychotherapy presumably works by changing the way we think about things – what is sometimes called a ‘top-down’ approach. Drugs, on the other hand, impact first on neurobiology in a ‘bottom-up’ fashion. Indeed, as the British neuroscientist Camilla Nord described in a Psyche Idea, her research into brain activation before and after treatment with antidepressant medication or psychotherapy uncovered striking results – there was no overlap between the brain changes, suggesting that the two approaches work differently, yet complementarily.
As far as I am aware, there is no evidence that antidepressants will impair your ability to deal with any psychosocial issues that might have contributed to or been caused by your depression or anxiety. There used to be a theoretical concern that they might interfere with the natural healing process after bereavement, but that does not seem to be the case – and that accords with my clinical experience, too.
Rather, I am all too aware that people are often so overwhelmed by stress, or so exhausted by insomnia, or in such a rut with depression, that taking an antidepressant actually helps them have the energy and motivation required to comply with psychotherapeutic demands.
What should I do if I don’t respond to my antidepressant medication?
Upon beginning treatment for depression or anxiety with an antidepressant, you might experience immediate symptomatic relief, and after a couple of weeks, it is usual to feel a little better. However, getting the full benefits typically takes two to three months for depression and can take even longer for anxiety. So, if at first you don’t respond, it is often worth waiting longer (so long as the side-effects are tolerable).
If you still don’t find any benefit, the next best and easiest thing is to try a higher dose of the same drug you’re taking already, which is something to discuss with your doctor. To give you some context, a family doctor will often start a patient on 20mg of fluoxetine or 50mg of sertraline, which can and often does work but, for the patients I see in a psychiatry clinic who have moderate to severe problems, a higher dose is usually required.
If a higher dose of the same drug does not work, or seems unlikely to, your doctor might propose trying another antidepressant of a different type. Based on my personal experience and some limited data, I’d say around 10 per cent of patients find they need to try a third or even fourth antidepressant before they find the one that suits them. This is also a good time to add in a structured psychotherapy, such as CBT or IPT, if you haven’t already.
Most people will respond to these manoeuvres. If you are still showing no signs of recovery, all the mental health professionals you’ve been consulting should review the situation and reconsider your diagnosis. Perhaps there is an ongoing stressor or unaddressed psychosocial issue that is still problematic. One issue to consider is that ‘self-medicating’ with alcohol or illicit drugs can prolong depression and interfere with the potential benefits of antidepressants.
How and when should I stop taking antidepressants?
Nobody likes taking pills or wants to do so for any longer than necessary. But, if you respond to an antidepressant, there is a lot of evidence that staying on them for a year or more will significantly reduce the chances of relapsing and becoming unwell again.
In a systematic review of 31 randomised controlled trials involving 4,410 participants, 41 per cent of people taking a placebo became depressed again, on average, compared with 18 per cent of people taking an antidepressant. In other words, staying on antidepressants more than halves the risk of relapse.
However, most people want to stop their antidepressant pills as soon as possible after getting well. They feel better and believe it should be safe to stop the pills – but that is often not the case, especially with moderate to severe depression because of the major risk of relapse.
Some of my patients opt to stay on antidepressants for years rather than risk becoming depressed again. As I tell them, there are no known adverse physical effects of staying on antidepressants in the long term. And, as they tell me, it provides assurance and reassurance that they will remain well. As one patient of mine put it:
I never want to feel as disgusting as depression makes me feel. Never again. So I’ll keep taking the pills.
When the time does come that you and your doctor are agreed that it is safe to stop taking the pills, be prepared that you might experience an ‘antidepressant withdrawal syndrome’. Do not be alarmed – this is not the same as ‘dependence’ or ‘addiction’ and is not unique to antidepressants. There are several drugs for ‘physical’ illnesses, such as the beta-blocker propranolol and the steroid prednisolone that also need to be withdrawn slowly, but no-one ever says patients are addicted to them. Usually, any withdrawal effects from antidepressants are mild and last only a few days. If they persist, it can be difficult to distinguish them from symptoms of a relapse of depression or anxiety.
You should review your experiences with your doctor, but my clinical rule of thumb is that if you start to feel as you did before treatment in terms of your mood and other symptoms, that is probably because you’ve stopped taking an effective drug treatment; on the other hand, if you feel differently than you did before, and in particular have symptoms commonly associated with drug withdrawal rather than anxiety or depression (such as ‘electric shock’ sensations, flu-like symptoms or sweating) then you are probably experiencing a withdrawal reaction that will soon pass.
If you have been on an antidepressant for months or years, then your doctor will advise that you need to reduce the dose slowly. How you do that should be discussed with your doctor, but halving the dose every couple of months and then reviewing things to check it’s OK to halve again usually works well in my experience. This is particularly true if you are on paroxetine or venlafaxine, which are more likely to cause withdrawal reactions than the other antidepressants. I also advise my patients to phase out antidepressants at a relatively good, stress-free time in their lives, perhaps at a time of year such as the spring or summer, when everyone tends to feel a bit brighter.
How should I deal with antidepressant stigma and pill-shaming?
Many ill-informed people seem to think that antidepressant use stems from emotional weakness, or an inability to deal with problems, and that people with depression should somehow ‘snap out of it’. Such mistaken ideas sometimes co-occur with a lack of belief in the therapeutic efficacy of antidepressants, despite overwhelming evidence to the contrary.
Although it is increasingly well recognised that people on antidepressants may face judgmental remarks from friends, family and colleagues, I am not aware of any good guides on how to deal with this. My advice would be to explain calmly that your depression is distressing and disabling, that the drugs do work, the side-effects can be managed, and that you won’t be taking the pills forever because you will phase them out once you are well again.
To my mind, the stigma of antidepressants is closely related to the broader stigma of depression and of all mental illness. The more people can be open about their illness and how they benefited from drug treatment, the less stigmatised depression and antidepressants will be. People who have written and spoken openly about their use of antidepressants include the eminent biologist Lewis Wolpert in Malignant Sadness (1999); the writer Andrew Solomon in The Noonday Demon (2001) and, more recently, the science writer Alex Riley in A Cure for Darkness (2021). Celebrities who have spoken about their positive experiences of antidepressants include the Canadian actress Annie Murphy and the US singer and actress Selena Gomez.
Besides therapy and pills, what else can I do to help?
I’m sure there are many things you have tried already. Comments such as ‘Just pull yer socks up’ and ‘Try a bit harder’ are part of the harmful, stereotypical blaming that occurs too often in the context of depression and anxiety. If you could somehow make yourself better, you would have! Indeed, most folks I’ve treated have tried to try harder, but have come up against the limitations of their condition. Usually, what you need to do, as difficult as it can be, is to disengage from your depression or anxiety, distract yourself from thinking about it too much, and do other things.
As I tell all my patients, there are ‘good common sense’ changes that just about everyone can adopt to promote recovery. We humans are creatures of habit and social animals, and among the daily routines that can help are: getting up at a regular time, getting out of the house for some exercise, even if just once around the block, and meeting up with someone for a chat.
More formal evidence-based approaches for depression include physical activity and mental exercises, such as meditation; and, for anxiety, there are various relaxation and other worry management approaches. Mindfulness meditation may have a particular role to play in reducing people’s chances of becoming depressed again. Physical exercise has a moderate treatment effect and a small preventative effect for depression. Yoga and tai chi are also worth considering, but I suspect that any form of exercise is the key rather than any particular approach.