As an overworked medical school student, Mark Horowitz started taking an antidepressant 20 years ago to lessen his gnawing anxiety about his future. The pill, escitalopram, helped, and he didn鈥檛 give it much thought as he took the medication every day for the next 10 years. He decided to stop after reading an article suggesting antidepressants鈥 effects tend to wear off over time, and tapered his dose carefully over several months. Even so, he says, his life 鈥渆xploded鈥.
He started having panic attacks, terror, dizziness and insomnia. His surroundings felt 鈥渄reamlike鈥, like he were losing touch with reality. The withdrawal was so much worse than the difficult but manageable depression that had prompted him to start on the medication. Horowitz eventually returned to the drug 鈥 not because he thought it was helping him, but because he found the withdrawal symptoms so unbearable.
He鈥檚 not alone. Escitalopram and other selective serotonin reuptake inhibitors (SSRIs) are common medications, billed as a safe way to mitigate depression with minimal side effects. However, of people are speaking out about the problems of trying to reduce or stop their dose. These concerns raise bigger questions about whether we have been misled about antidepressants鈥 harmlessness and become overly reliant on them as a way to treat depression, anxiety and other mental health challenges.
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is now a psychiatry research fellow within the National Health Service (NHS) in England, and a leading voice pushing against the current approach to antidepressants. A of recent 鈥 including 鈥 supports his experiences, and this growing evidence is finally having an impact, changing how we treat depression.
How SSRIs became so popular
In the nearly four decades since SSRIs were approved for medical use, they have embedded themselves into everyday life. of people in the US now take antidepressants, the majority of which are SSRIs, according to an analysis of census data published in January, along with of those living in the UK and .
SSRIs weren鈥檛 the first antidepressants, but they became blockbuster drugs precisely because they are safer and have fewer side effects than other medications approved to treat depression. Earlier antidepressants like tricyclics served as effective treatments, but they also come with complex risks such as irregular heartbeats and tremors, and can be toxic at high doses. SSRIs, by contrast, result in less serious side effects, including nausea, sleep disturbances and sexual dysfunction. Because of this lower risk profile, they quickly became the go-to treatment for depression and anxiety.
There are good reasons to support their use. A survey of nearly 20,000 people in the UK taking SSRIs found that nearly three-quarters felt they were useful, though this figure is likely to be inflated by the placebo effect. Still, a of more than 670,000 people with depression found the drugs had small to moderate effectiveness.
But because SSRIs are purportedly so much safer than earlier antidepressants, clinicians and those taking them to the same extent as . As a result, SSRIs have been widely prescribed for decades with little advice on how or when to revisit prescriptions. A reviewed clinical practice guidelines issued by national health authorities in countries including the US, UK, Australia and Canada and found that none provided concrete instructions on how to reduce dose or manage withdrawal symptoms.
This means that, when people start taking antidepressants, they are often on the drugs for the long haul 鈥 whether they intended to be or not. A study showed that people in the US now take SSRIs for a median of five years, with over a quarter taking the pills for a decade or longer.聽
Yet such long-term use hasn鈥檛 been thoroughly studied. The average length of a trial for antidepressants聽is聽just eight weeks, meaning that our clinical understanding of their side effects is also limited to that time frame. 鈥淯nfortunately, there are a lot of things that are still unsettled,鈥 says , a psychiatrist and researcher at Texas A&M University, and there isn鈥檛 strong data on how long-term use affects efficacy and withdrawal symptoms. Some researchers believe that the longer someone stays on the medication, the greater their risk of side effects. 鈥淭he聽longer you鈥檝e been on the antidepressant, the more likely withdrawal symptoms are, the more severe they are, the more difficult it is to stop,鈥 says , a clinical psychologist at University College London, who studies antidepressants.
People like Horowitz have found that, when they do decrease their dose, the symptoms can be intense. These psychological difficulties are often misinterpreted as manifestations of the original condition 鈥 a phenomenon referred to as relapse or recurrence 鈥 and for the drug or increasing the dose. 鈥淧hysician non-recognition of withdrawal often leads to gaslighting or to misinterpretation of symptoms as relapse, necessitating longer-term treatment,鈥 says , a neuroscientist at Harvard University and the former director of the US National Institute of Mental Health.
Horowitz knew his own withdrawal symptoms weren鈥檛 a recurrence of his depression. After all, he had never experienced insomnia, panic attacks or the sense that he was living in a dream 鈥 the symptoms he experienced after quitting escitalopram 鈥 before taking the drug.
There鈥檚 now growing evidence to validate his experience. Last year, Horowitz co-authored a surveying more than 300 people who stopped taking their antidepressant (or tried to) and found that nearly four-fifths reported some type of withdrawal side effects, with 45 per cent experiencing moderate or severe difficulties. The study focused on physical signs of withdrawal symptoms such as headaches, dizziness, electric shock sensations (often referred to as 鈥渂rain zaps鈥) and vertigo, to distinguish withdrawal symptoms from depression relapse.
鈥淭here are widely differing views on how prevalent moderate to severe withdrawal effects are with these drugs,鈥 says , a psychiatrist at the University of Bristol, UK, but many believe they are 鈥渕uch more common鈥 than previously acknowledged. A 2024 analysis looked at more than 16,000 people who stopped taking various antidepressants, including SSRIs, SNRIs (serotonin-norepinephrine reuptake inhibitors, which are used similarly to SSRIs) and earlier medications like tricyclics. The researchers estimated that , with two SNRI medications most frequently causing such effects, and around 1 in 35 experiencing severe symptoms. Another paper, co-authored by Horowitz and published the same year, surveyed 1148 people who tried to stop taking their antidepressants and found that , while 1 in 4 were unable to stop their medication.
Overlooked risks of long-term use
In addition to the withdrawal side effects, emerging research also suggests that antidepressants come with other risks.
Earlier this year, researchers at Copenhagen University Hospital聽聽revealing a strong correlation between long-term antidepressant use and sudden death caused by the heart unexpectedly stopping. Individuals who had been taking antidepressants聽for at least six years had a 74 per cent increased risk of experiencing a fatal cardiac event.聽
The previously unknown risks go beyond heart health. A paper found that individuals in their 70s and 80s who were prescribed SSRIs experienced 鈥渟ignificantly faster global cognitive decline鈥. Likewise, found that people with dementia who were taking antidepressants experienced more rapid cognitive decline. 鈥淪ometimes we think a lot about medications when we start them, but we don鈥檛 think enough about stopping them at some point,鈥 says , a neurologist at the Karolinska Institute in Sweden, who worked on the study.
Doctors occasionally prescribe SSRIs to improve cognition in older people, and there鈥檚 that they can be helpful, by virtue of alleviating depressive symptoms. But , a psychologist at McMaster University in Ontario, Canada, believes the risks exceed the benefits. SSRIs may be beneficial in the short term, he says, but long-term use suggests 鈥渕ore of a negative or increased risk鈥.
The 2023 study also found that people taking SSRIs had a greater accumulation of tau tangles in their brain neurons 鈥 a hallmark of Alzheimer鈥檚 disease 鈥 though it isn鈥檛 clear whether the tangles were driven by SSRI use or if the behavioral symptoms associated with them prompted physicians to prescribe antidepressants.
The studies don鈥檛 definitively show that cognitive decline and dementia are caused by antidepressants, rather than by depression itself, says , a psychologist at the University of Toronto. 鈥淭hat鈥檚 the kind of stuff that鈥檚 really hard to control for in research,鈥 she says. But they still reinforce a growing sense that SSRIs have been embraced and prescribed without enough scrutiny of the dangers they pose.
Not everyone shares the view that antidepressants are overprescribed or is confident that withdrawal symptoms cause serious side effects. Guinjoan, for example, says the risks of not prescribing antidepressants and leaving depression untreated outweigh the potential effects of withdrawal symptoms. , a lecturer in psychological medicine at King鈥檚 College London, says she has seen both: 鈥淪ome have had very negative experiences with antidepressants, while others have seen them make a profound positive difference and even save lives.鈥
A new treatment paradigm
All this new research raises questions for those who are currently taking SSRIs. Should they attempt to come off their antidepressants? And, if so, how? Both Kessler and Buckman emphasise that anyone considering this must talk to a doctor first. After Horowitz went back on his SSRI to assuage his withdrawal symptoms, he turned to online support groups for guidance on how to taper. He eventually managed to wean himself off completely, but it took him far longer than official US guidance suggested. 鈥淭he guidelines in America said you can come off antidepressants in about six weeks,鈥 he says. 鈥淚t took me about six years.鈥
He has since created Outro Health, a clinic to help people safely taper off antidepressants, and has also developed a new, more methodical approach to tapering, which he outlines in the Royal College of Psychiatrists鈥 and the first-ever on discontinuing medication. People should taper at a rate they can tolerate, he writes. If they start experiencing withdrawal symptoms, they should stay at that dose until the effects subside, or even increase the dose slightly if symptoms are too difficult to bear. To taper this slowly, he says, liquid versions of the SSRI need to be used, rather than traditional tablets, to allow the dose to be accurately reduced in small increments.
This work has informed and the NHS in the UK, which once characterised antidepressant withdrawal as mild and short term. Earlier this year, the American Society of Clinical Psychopharmacology also published , advising clinicians to periodically reassess the value of psychiatric medication prescriptions 鈥渁t the very least, on an annual basis鈥.
As more psychiatrists question long-term SSRI use, health services in the UK are engaging more with alternative solutions. Exercise and talk relieve depression at similar rates to antidepressants, and come with none of the side effects of medication. New guidelines for England and Wales on treating depression include a for less severe manifestations of the condition, including cognitive behavioural therapy, mindfulness and meditation.
Taken as a whole, this nascent shift in psychiatry isn鈥檛 about renouncing SSRIs. Some people, such as those with obsessive-compulsive disorder or life-threatening depression, may need to take SSRIs for years. And for those with situational depression, SSRIs can often be beneficial in the short term. But a new understanding of the effects of withdrawal symptoms seeks to reframe SSRIs as part of a larger, more diverse treatment package.
From Horowitz鈥檚 perspective, a key part of this shift will come from people starting to manage challenging life circumstances without assuming that drugs are the answer. Plenty of people need help, he says, but this doesn鈥檛 always necessitate medication: 鈥淵ou need time, you need support, you need therapy. We need to start giving permission to both doctors and patients to move beyond drugs.鈥
