Antidepressants are a common treatment for depression. More than one in ten people in the United States take prescription medicine for depression, according to the Centers for Disease Control and Prevention.
These medicines are now in the spotlight amid an ongoing debate over how well they work and their possible side effects.
In this Q&A, Amirhossein Modabbernia, MD, PhD, Assistant Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, explains how antidepressants can help. He also explains what you can do if they do not seem to be working, including how to talk with your doctor about stopping your medication.
“I think people should know that depression is real, common, and treatable, and that needing medication is not a weakness or a moral failure,” he says. “At the same time, antidepressants are not magic, and they are not the right answer for every person or every situation.”
How can antidepressants help people with depression?
Antidepressants can help many people. They may be most helpful when depression is moderate or severe, lasts a long time, or keeps coming back. These medicines can lower symptoms enough so a person can sleep, think clearly, connect with others, work, enjoy life, and start dealing with life’s problems again.
In my work with patients, people often describe the change by saying, “Something has lifted,” “I can think and function again,” or “There is a little more space between me and the depression.” Large studies do show that antidepressants outperform placebo on average, though the benefit varies substantially from person to person. Medication is not the whole answer for everyone. But for many people, it can create the mental and emotional space needed for recovery, therapy, relationships, and meaningful life changes.
Amirhossein Modabbernia, MD, PhD
What if I am taking an antidepressant but do not feel better?
The first thing I would say is: Please talk honestly with your doctor. A poor response does not mean treatment has failed forever. It also does not mean you should stop the medicine suddenly. It is important to have realistic expectations. Antidepressants usually do not create instant happiness. They do not take away all emotional pain. Early signs of improvement can be small. You may sleep better, have more energy, feel less weighed down, think more clearly, feel less irritable, or find it easier to get through the day.
What can I do if my antidepressant does not seem to be working?
If the medicine is not helping enough, that is useful information. It may mean:
- The dose is not right.
- The medicine needs more time to work.
- Side effects are getting in the way.
- The diagnosis needs to be looked at again.
- Other issues are playing a role, such as sleep problems, substance use, medical problems, trauma, or major life stress.
Sometimes psyhotherapy needs to be added. Sometimes the medicine needs to be changed. Sometimes the whole treatment plan needs to be adjusted. The important point is this: If you are not improving, that is not a dead end. It is a reason to talk with your clinician and decide what to do next. If you feel worse, have side effects you cannot tolerate, or have suicidal thoughts, talk with a clinician right away.
What should I do if I want to stop taking my antidepressant?
Do not stop suddenly unless there is a clear medical reason and a clinician is guiding you. Stopping an antidepressant can be a reasonable choice. But it should be done with care. Before stopping, you and your clinician may want to talk about questions such as:
- Why do I want to stop now?
- How long have I been feeling well?
- How stable is my life right now?
- What happened the last time I stopped, if I stopped before?
- What symptoms should we watch for?
- How slowly should I lower the dose?
- What is the plan if depression comes back?
Withdrawal symptoms are real. They can include dizziness, nausea, trouble sleeping, irritability, anxiety, vivid dreams, flu-like symptoms, and sometimes “brain zaps,” which can feel like electric shocks. This does not mean people should be afraid to stop. It means stopping should be planned. It should be done slowly, with a clear follow-up plan.
How do you decide if someone is ready to lower the dose?
I usually want to know if the person has been well—not just a little better—for a steady period of time. I also look at whether the person is functioning well again. I want to know if major stressors are stable, if the person has support, and if there is a plan to prevent depression from returning. That plan might include therapy, steady sleep routines, exercise, social connection, awareness of early warning signs, and a clear plan for what to do if symptoms return.
I also look closely at the person’s history. Someone who had one mild episode of depression is different from someone with depression that keeps coming back, or someone with long-term depression, suicidal thoughts, a history of hospitalization, severe anxiety, trauma, substance use, or possible bipolar disorder. Past attempts to stop medicine also matter.
Many guidelines recommend staying on antidepressants for several months after symptoms improve after a first episode. They recommend staying on them longer when depression has come back, lasted a long time, or been severe. So tapering is not only about preference. It is also about timing and safety. Is this a good time to try? And do we have a plan if symptoms get worse?
Are some antidepressants harder to stop than others?
Yes. Some antidepressants are more likely to cause symptoms when they are stopped, especially if they are stopped too quickly. In general, medicines that leave the body quickly can be harder for some people to stop. Examples include paroxetine, brand name Paxil, and venlafaxine, brand name Effexor. Fluoxetine, brand name Prozac, often causes fewer symptoms when stopping because it stays in the body longer. But every person is different. That is why the taper needs to be personalized.
Are there options other than antidepressants?
Yes. Antidepressants are only one part of depression treatment. Therapy can be very helpful. This can include cognitive behavioral therapy, also known as CBT; interpersonal therapy; behavioral activation; psychodynamic therapy; and mindfulness-based approaches. For many people, therapy is as important as medicine, and sometimes it’s more important.
It is also important to look at the full picture. Sleep, substance use, exercise, social isolation, daily routine, trauma, medical issues, and the person’s life circumstances all matter. Depression does not happen in a vacuum. For more severe depression, or depression that has not improved with treatment, other options may be appropriate. These can include transcranial magnetic stimulation, electroconvulsive therapy, or ketamine or esketamine. The right approach depends on the person. It depends on the severity of depression, safety, past treatment response, preferences, access, and what is realistic in that person’s life.
Why should I talk with a clinician?
Good treatment should be a partnership. People should feel able to ask questions and speak honestly about what they are experiencing. Tell your clinician if your medicine is not helping, if side effects are affecting your life, if you feel emotionally numb, or if you want to stop taking the medicine. These are all valid things to discuss. The goal is not just to lower symptoms on a checklist. The goal is to help people return to a life that feels more livable, connected, and meaningful.