The issue of who an antidepressant should be prescribed for and in what situation it should be taken was covered in the last post. I have no doubt that this post will generate a lot of debate and comments from passionate well-intentioned people. What I am offering in this post are my thoughts on the topic. Thoughts based on having advanced training in mood disorders and psychopharmacology and being on the front line attempting to help hundreds of patients with mood disorders. But more importantly, as you have seen in my previous blog posts, as someone who tries to prescribe medications thoughtfully and carefully in the proper situations.
My answer to the question is NO. People who are prescribed antidepressants do not become "addicted" or "dependent" on them. In fact, if my patients did become "addicted" compliance rates with antidepressants would be much much higher than they are. Unfortunately many people forget to take their antidepressant even when it is helping them, a common problem in different medical specialties. It IS true however that sometimes tolerance develops to an antidepressant after it has been working for a while and some people develop withdrawal symptoms as they attempt to come off an antidepressant. Paroxetine and venlafaxine are especially notorious for this so-called SSRI discontinuation syndrome. So some people develop tolerance and some will have withdrawal with antidepressants. Is this not addiction? No, let me explain.
I will focus on three aspects:
First, I have a problem with the terms "addiction" and "dependence" in this context. These terms are generally reserved to be used for illicit substances of abuse or self-destructive behaviors. The medical use of antidepressants clearly does not fit into this category. Can we say that someone who takes an inhaler for asthma or medication for high-blood pressure is addicted to it?
Second, persons taking antidepressants do not display classical addiction or dependence behaviors. In contrast to cocaine for example, they do not have a problematic misuse that leads to physically or legally hazardous situations. They do not spend all their time, energy and finances desperately seeking antidepressants or recovering from their effects. They do not give up their relationships, obligations, academics and jobs to continue using an antidepressant. In fact, in those who respond, much of these aspects will improve!
Third, people do not misuse antidepressants to reach a state of euphoria or unnatural perception. In most people where the use of an antidepressant is sanctioned it will, in fact, help them re-achieve their normal state and emerge from the altered negative perceptions that depression is causing.
Depression is a major and potentially life-threatening illness. It is projected by the WHO to become the #1 cause of disability and lost productivity worldwide in the next decade; surpassing cancer and heart disease. Unfortunately we still don't have a perfect weapon to fight depression. Just like steroids are not the perfect weapon to fight asthma, rheumatoid arthritis or autoimmune diseases. Physical exercise, proper nutrition and psychotherapy are important and under-utilized tools in the fight against depression. I have written extensively about the role of exercise in treating depression here, here and here. Antidepressants, like all drugs, can have negative effects. But the research, clinical experience (including my own), patients' reports and history all show that these medications have been a significant step in reversing this awful illness.
We need better treatments for sure. But the spread of untruths about antidepressants, like saying they are "addictive" or cause "dependence" is a diservice to public health. A more thoughtful and nuanced stance would be to say that these are helpful medications when used in the right situations. That unfortunately they are over-prescribed for some who don't need them and under-prescribed for many who do. And that antidepressants are not perfect but are a significant step forward while we continue working towards that ultimate research goal: Finding the cure for depression.
That is what I stand by and will continue to advocate.
