Jacob Z. Hess, Ph.D.

Between 2005 and 2009, I conducted a dissertation study exploring contrasting narratives of people on antidepressants after years of treatment. During my defense before the committee, a professor asked me, “So why are so many people in Utah on antidepressants?”[1]

Most people have heard one especially fashionable explanation, which attributes this pattern largely or entirely to the LDS Church itself, especially to high standards and expectations intrinsic to Mormonism (and arguably to Christian discipleship generally).[2] Without denying these as real issues worth exploring, it’s difficult to claim that these cultural elements drive rates of depression among Mormons – especially when Mormons experience depression at comparable rates to the rest of the population[3] and depression continues to prove itself as a universal epidemic spanning all boundaries.

So in that moment, I raised another possible answer for my dissertation committee: “Well, conservative people trust authority, you know! And compared to my liberal friends who pepper doctors with all sorts of questions, when a physician informs my neighbors in Utah that this medication is going to take care of your problem….well, most of the time they pretty much believe it. I’ve seen many instances of neighbors who feel uncomfortable at what their doctor is saying, but ultimately go ahead and follow (obey) the prescribed order!”

Compliance & intuition. In many times of life, of course, this “willingness to obey” is a good and even crucial thing – including, perhaps in relation to a doctor’s prescription.

And, indeed, studies show that a certain percentage of people on antidepressants can and do experience some kind of short-term relief (varied figures depending on the study, the sample and the severity of depression),[4] with another group sometimes finding relief in a second or third or fourth attempt. For someone in a desperate place, this bit of relief can mean a lot – and might even be life-saving.

As most people are, I am absolutely supportive of people following their intuition and personal sense of what is best in getting the help they need. That, however, is sometimes where our public conversation stops – with lots of collective attention focused on helping people move from a place of fear or stigma, to an openness to “getting help.”  But what happens next?

That’s been the focus of my research.  We’ve all heard vivid stories detailing heartening shifts some people experience after starting something like an antidepressant.

So what happens next  – after the miracle moment?

Looking long-term. In 2009, after losing a friend to suicide, one of my colleagues Bob Whitaker started exploring the same question. He gathered together every single medical study exploring long-term outcomes of psychiatric medications, including antidepressants. And what he found surprised him.

As expected, antidepressants showed short-term improvements for patients (which is why the FDA approved them for public use). But looking long-term, these same medications show more counter-intuitive effects. Similar to other drugs (antianxiety, antipsychotics, and pain-killers), longer-term results are consistently underwhelming, and even alarming. In particular, the following pattern kept emerging:  People on antidepressants long-term, compared to comparison groups, were more depressed than those not (see pages 164 -169, in particular).

This pattern showed up again and again, with several different research indicators pointing in the same direction (see also pages 157-163).  Generally speaking, people taking antidepressants long-term don’t fare so well. That’s the simple truth.

Fear of tapering. If that’s true, then why do people stay on them long-term? Because they have become convinced they cannot live without them – and the withdrawal effects they experience in attempting to taper seem to only confirm that.  

In my own study, for instance, I found that when people tried to taper off an antidepressant, they were often encouraged to taper so quickly (“cut your dosage in half”) that withdrawal effects overwhelmed them. Rather than see this turbulence as reflecting withdrawal effects, however, most people interpreted them as the “return of depression.” That, in turn, became evidence of how much “I really need this” – even though, by this point, many people seemed to experience little to no real therapeutic effect. After many years, in other words, many people end up essentially deciding to stay on the drug to avoid the bad effects that sometimes arise when they taper (which they interpret as a “return of the depression”).[5]

One woman told me, “I’m grateful that I was born in this day and age where I could get the medication that I need so that I wouldn’t be locked up in the attic somewhere, or indisposed all the time (laughs).” Another person added, “I’d really like to be off the meds, but the person off the meds is scary” (p. 90).

As reflected here, many people learn at some point that they cannot be okay without the antidepressants. What may have been a helpful message to prompt people to get help in the first place, seems ironically to contribute to a longer-term dependency on the medication. And indeed, many professionals now just assume that depression has a natural long-term course – without questioning why so many people seem to be finding that to be true now, compared to previous eras.[6]

Another way forward. But it doesn’t have to be this way! The medical research confirms literally hundreds of potential contributors to depression, alongside hundreds of things people can do to begin moving in a direction of long-term healing.[7]

To be very clear: If an antidepressant has helped you move towards healing, wonderful!! All I’m pointing out here is that antidepressants were never intended (or tested or proven) to be a long-term remedy. So appreciate whatever help they have offer you now, but be sure to leverage that time to create an infrastructure for longer-term healing.[8] And you may or may not like to hear this: but as part of that plan, consider the possibility of tapering off antidepressants as a part of your sustainable healing package.

When that time is right (and you and your loved ones are the best ones to know that, ideally in consultation with a doctor),[9] you can begin the task of tapering off antidepressants. For people who have been taking antidepressants for years, this will not (and typically cannot) be a quick process, with a need for careful medical management and support. The time and way of doing that needs to be carefully considered – and once again, hopefully with the supervision of a doctor.[10]

Am I telling you to get off a medication?  

No, I do not have that authority. I am raising a question that others can consider for themselves.  Although I have received a doctorate with a focus on this area of research, I cannot say whether or when it’s right for any given individual to consider the possibility of tapering off antidepressants. That depends on many factors only known to you. In other words, the information contained here does not constitute medical advice and should not be relied on as such. Furthermore, these are my own thoughts and do not represent any institution or person with whom I have collaborated. 

I acknowledge (and expect) that some will see this as a dangerous possibility to raise – especially those convinced that patients have an inherent need for the medication.[11] Clearly it’s not time for everyone to taper off Prozac – since for some, it may be contributing to their well-being for now. I acknowledge that possibility here.

To not acknowledge the other possibility however – that tapering may be beneficial for people’s healing at some point (and that there are possible detriments for not doing so) – is I believe unethical. In a moment when one in 10 Americans (and one in four middle-aged women) is on an antidepressant AND STILL the burden of chronic mental illness appears to be accelerating,[12] the last thing we want to do is foreclose fresh possibilities. Indeed, the possibility I raise here could be phenomenally good news for people who have experienced depression for years. Instead of looking forward to yet-another-year simply “managing or coping with their depression,” this invites space to at least consider higher levels of well-being available.[13] And indeed, the good news is that it’s not only possible, but that long-term, people can start to feel more themselves again after getting off antidepressants.

For those interested in hearing more about this broader approach to working with mental/emotional distress, check out this free online course available here – Mindweather 101: Creative ways to work with intense thoughts and emotions – a class drawing on insights from many professionals and researchers.

Invitation to those with questions. For those who remain skeptical at any of this and see it as falling somewhere on the spectrum from silly to dangerous, I leave two challenges:

• Read this chapter summarizing the historical and scientific case behind my question and concern.
• Watch this 6 minute video on Learned Hopelessness.

After doing both, ask yourself the following:  “Is it dangerous to let people know of the possible benefit of deep, long-term healing available (and not exclusively dependent on medication) or is it dangerous NOT to inform them of this?

In order to expand my own understanding, I’m gathering stories of people’s long-term experiences with depression (whether on or off antidepressants, whether doing well now or not so well).  If you have a story you’d be willing to share, contact me at Jacob@alloflife.org. I would like to better understand more of people’s long-term experience – especially those who have interest or experience pursuing tapering after many years.

I welcome any and all questions and inquiries.

Notes:

[1] The evidence for this contention comes from a single 2002 study that has been widely cited and more often than not taken to be definitive causal proof that Mormonism is causing people to be depressed.

[2] These high standards and expectations are referred to almost universally as a pejorative within general public discourse – e.g., “perfectionism, shame, busyness.”  And yet, for Christians who worship a Risen Lord who asks followers to “take up your cross” and “seek not to save your life, but to lose it” – for people who earnestly believe that God is asking for their hearts, minds, lives, loves – and even their bodies as “living sacrifices” – for these people they are aware these requests will never be understood by the natural man as anything but “foolishness.”  Thus, while there are legitimate ways to improve how Mormons talk about expectations (indeed, this is a big purpose of my blog), most active members – myself included – see the public attacks on shame, standards etc. as significantly hyper-exaggerated within an American cultural context that has come to see any boundary, distinction or expectation that might invoke some kind of personal discomfort to be a major problem.

[3] While some have insisted Mormons are more depressed than everyone else (pointing, for instance, to one study suggesting higher rates of anti-depressants), a broader review of evidence  confirms a more nuanced picture:  namely, Mormons often reflect a similar depression rate to the national average, with some evidence suggesting active members are less depressed than the national average.

[4] For instance, this conclusion from one 2010 meta-analysis: “The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.”

What exactly it means for a treatment to be “successful” or “effective” is another point of sharp disagreement, however, as Jeff Lacasse and I explore here:  “What Does It Mean for an Intervention to ‘Work’? Making Sense of Conflicting Treatment Outcomes for Youth Facing Emotional Problems”

[5] Physicians often make the same interpretation – “You see?! That just shows why you need to say on this medication.”  Dr. Joseph Glenmullen, associated with Harvard University, was one of the first doctors to suggest another interpretation – namely, that withdrawal effects were at play in these negative effects arising after people begun tapering (and that these were often being misinterpreted as a simple return of depression.”

[6] In previous eras, depression was taken for granted to be time-limited  – with early reports consistently suggesting high rates of people finding recovery (See Bob Whitaker’s summary of the history)

[7] Our own review of the medical literature has pointed towards numerous factors contributing to serious depression – each suggesting a possible point of intervention and adjustment.

If true, of course, this would be a possibility for anyone on antidepressants, Latter-day Saint or not (with the latter the primary audience of my blog).

So what does this have to do with mindfulness anyway?  Mindfulness is about increasing our awareness – of body, mind, heart and the world around us. I raise this as an area of exploration with vastly insufficient awareness currently – hoping that greater awareness will be helpful to individuals and families who are struggling.

[8] And don’t be surprised if the medication doesn’t offer you relief.  For some people, they will never respond positively to an antidepressant.

If you are interested in learning more about this approach to healing, check out Mindweather 101 – a free online class prepared over several years and drawing on 35 professionals.

[9] But what if you cannot find a doctor willing to supervise you? This is especially common given how many doctors have been fully convinced of the long-term chronicity of depression. Despite that, there are doctors willing to work with people interested in tapering, and who will support individuals following their sense of what is best.  It is ideal when professionals support individuals in families in following their intuition of what is right, rather than overriding that by strong counsel.

[10] Read all you can about the process to get informed.  I will only provide this guideline written by a doctor I trust at Harvard Medical School, since I want to stay far from the line of any specific recommendations. But with enough searching online, you can find various additional recommendations for a thoughtful wise, gradual, stepped, withdrawal plan.

[11] There are very different views of the physiological basis of mental/emotional problems. Depending on the view taken, it leads to very different conclusions about treatment. For an academic length treatment of this question, see this peer-reviewed paper published with several academics across the country: “Narrating the Brain Investigating Contrasting Portrayals of the Embodiment of Mental Disorder”

[12] This comes from an analysis by Elizabeth Kantor at Harvard University of a survey of nearly 40,000 adults, from 1999 to 2012. She found that the percentage of Americans on antidepressants had doubled over this period.

[13] There are, of course, very different views about recovery from depression and serious mental/emotional challenges:  What exactly does it mean? What is realistic to expect, either short- or long-term? In collaboration with a set of diverse (and disagreeing) collaborators, we explored these questions in this peer-reviewed article here: “’Is There a Getting Better From This, or Not?’ Examining the Meaning and Possibility of Recovery from Mental Disorder.”