I don't think SSRIs are harmful. Otherwise, I wouldn't be prescribing them, but I do think that there are times when they're misused or they're not monitored safely enough or people have problems with them and we need to address them. And I certainly think that therapy needs to be available. If RFK and the current administration said, 'We're going to devote a billion dollars to making sure that every child in America and their family has access to child therapists and in the schools, not just in offices.' I'm there.
I'm David Wallace-wells. I'm a writer for New York Times Opinion and a columnist for the Times magazine.
And I'm Rachel Bedard. I'm a primary care physician and a contributing writer at New York Times Opinion.
One in six Americans is on antidepressants. And a lot of Americans think that number is too high. That we're prescribing too many SSRIs. That we're giving them to children too young. And that we don't really know how to get people off those drugs even when they want to. The nation's top health official, RFK Jr., is kind of leading the charge.
Health and Human Services Secretary RFK Jr. are launching a new initiative targeting the overuse of psychiatric drugs, especially in children. The new plan urges doctors to prioritize holistic care like exercise and nutrition instead.
But RFK and MAHA are not alone. People have been debating these drugs and their effect on our society for decades. We're in a new moment now where people are arguing about it more. And Rachel and I have been talking a lot this summer about these issues. But that conversation is often at the highest level and ignores a lot of the clinical experience. What this looks like on the ground between patients, kids, their parents, and their doctors.
As a primary care doctor, I currently work in a homeless clinic. I previously worked on Rikers Island in the New York City jail system. I've always worked in populations where there were very high incidents of comorbid mental health issues. And as a primary care doctor, I've prescribed antidepressants and medicines for anxiety to patients hundreds of times, probably thousands of times, and have thought about these questions a lot myself around how I'm selecting patients who are good candidates for medicine and when I'm choosing to medicate them frankly because I can't get them access to other services I wish I could get them access to like talk therapy.
So to hash this all out we've invited Dr. Anthony Rostain to join us today. Dr. Rostain is the chair of psychiatry and professor of psychiatry and pediatrics at Cooper Medical School of Rowan University. Thank you so much for being here.
I'm so happy to be here. Thanks.
So, let's start with some history. Where did SSRIs come from? Why did they seem like a very big deal? And how did they become so successful in the sense of so many Americans coming to use them so prolifically?
Well, first of all, the SSRI ushered from my point of view a new era in psychopharmacology.
It was introduced by the FDA approved it in 1987. I happened to have been at 10 when it was being tested. So, as I was a resident and I saw that patients were taking it, were getting better and that they weren't having side effects that some of the other antidepressants had. At the time the primary antidepressant in use were in classes called tricyclic antidepressants which are still used occasionally and they had a lot of side effects and potentially harmful side effects, arrhythmias, people could accidentally or on purpose create situations where they would die from an overdose. So the fact that this medication came along, there was really tremendous relief at the ability to prescribe something that is safer and better tolerated.
How they evolved is a whole story in and of itself of how science, medicine and society evolved. Because initially they were approved primarily for depression and little by little the use was extended to anxiety, to obsessive compulsive disorder, to social anxiety and to PTSD. Suddenly we saw many uses that we could use the same medication for. And we've all wondered in the clinical field and in the general policy field at what point are we doing this safely? And I think it's healthy actually to be having this conversation right now.
So you mentioned there in talking about that history the contrast with the previous class of drugs primarily in terms of the safety that you could feel comfortable giving this to more patients because the risk of some serious side effects was much much lower. Back in time imagine we're still in the late 80s early 90s. How did the contrast look in terms of efficacy? Was there also a marked benefit that hadn't been seen in the previous?
There was a sense that these were as efficacious and better tolerated. Forgetting about the serious side effects, I think the overall early studies showed that yes, you could have a really good impact on moderate to severe depression with these SSRIs.
I'm wondering if we can talk a little bit about mechanism and how the sort of theory of mechanism has changed over time from one that was quite simple, the idea that the SSRI meant that you had more serotonin, a happy transmitter sort of soaking your brain, to where we are now where there's more nuance to how we think they work.
Yes. Yes. So, it's true. I mean, I trained in a time when everybody had hypotheses. If you had schizophrenia, you had too much dopamine. If you had depression, you had too little serotonin. It isn't that simple. And the brain is obviously more interesting and we understand it better than just a chemical imbalance. So what we think, number one, we know that all SSRIs do the same thing. They slow down the recycling of the serotonin molecule, which is a neurotransmitter, very important neurotransmitter. But what it really is doing over time is reshaping the circuits in the brain that affect our mood, that affect our ability to handle stress, that allow us to make sort of less reactive kinds of decisions.
And over time, I think what we really come to look at is neuroplasticity is the term we use now. When we're stuck in a depressed state or when we're anxious all the time, we can't learn. Okay? Our brains are locked into a pattern and neuroplasticity is actually the mechanism by which we learn. So clinicians talk, we talk to our patients about the idea that if we give you this medication, not only will you feel less depressed or less anxious, but you'll be able to learn some new tricks, right? And that's the idea is that this helps your learning and adaptation.
And that's really interesting though because the notion of depression as a chemical imbalance was sort of culturally accepted for a long time and was the way that people conceived of this and frankly was the way that I think lots of doctors spoke to their patients about it. There's a chemical imbalance and we can give you this medicine that will resolve that. I don't know that people think of depression as something where their brain needs to be rewired and that idea can be pretty scary for people.
Of course, of course. What are you doing to my brain? That's what people want to know, is this going to change my brain and if so, is that going to be a good thing. So what we're trying to get at with depression, we sort of have this model in our minds now that the circuits in the brain that modulate your mood seem to not be allowing you to feel positively and you're so stuck in this circuit of negative emotions. Actually the brain has two different circuits. One for positive emotions, one for negative emotions. So one way I explain it to patients is to say the positive emotional circuits are underpowered right now and the negative ones are running the show. This might quiet the negatives and allow the positive ones to be more present.
Is it a permanent rewiring? No. Because if we stop the medication, you go back to baseline. But hopefully when you do come off the medication, say your depressive episode is over with, you will have learned how to feel better and you will be able to push back against the negative more effectively.
I think we're going to talk in a minute about going off the meds, but just to stick on this point for a second and to raise a kind of, you know, an ignorant reflexive response. How strange is it that we developed this tool of drugs with one theory of depression, have evolved past that theory of depression, observed the drugs still basically working, and are continuing to prescribe them? How unusual is that? How unnerving should that be? Do you understand it when patients express a lot of doubt about this?
Let me say, to be quite honest, we still don't know what depression is or exactly how these drugs work. And you know that doesn't stop us from using them because people are coming to our office saying I'm in pain. I need help. I mean the same by the way is true for pain medications and pain syndromes. I mean these are really interesting. The brain is a fascinating organ and unfortunately we have to simplify this because we don't have any better way of explaining it at the moment. With new non-pharmacologic interventions like transcranial magnetic stimulation we can begin to think about oh maybe we can change your brain in positive ways without you having to be on a medication.
So this is where some of my own, you know, sort of I guess I would call it a kind of naturalistic fallacy comes in. I have some tendency to think, you know, if we understand the precise mechanism that, you know, insulin regulates blood sugar in the blood, I trust that it's appropriate to intervene when that's necessary. But if we're much more confused about the system, I have a little bit of a pause about the idea of taking meds like this and certainly prescribing them on mass as we've done. And I wonder if we could just talk a little bit about what we know at the level of population about how effective they are. How should we think about putting aside the mechanism just looking at whether they're working or not? What's the lay of the land state-of-the-art understanding of that question?
Well, to begin with, what we've learned from all the studies is that even if they are effective for a population, the patient in my office is going to have their own idiosyncratic risk. So therefore, it's not a one-size-fits-all. Like no, SSRIs don't work the same for everybody. So these population studies tell us that there are good effect sizes, not curative to everybody. There's still a lot of treatment resistant depression. People are started on this medication and they're still depressed fairly commonly and as a psychiatrist I see the cases of people who haven't been effectively treated by the first line of treatment.
The second thing and this is really important. And I always like to say, yeah, insulin and diabetes is a beautiful mechanism. We know it and sickle cell. We know that. But what about hypertension? You know, what about risks for stroke? What about even obesity? We don't know how these things are actually operating. We know lifestyle affects those, but there's genetics as well. We don't understand the genetics of these disorders as well as we'd like because we don't really know how to translate the clinical phenomenology back to the genes or to the mechanism of whatever life did to you over the course of time that made it harder and harder for you to feel like I can get up every day.
It's interesting because I also think we sometimes ask harder questions of the brain drugs than we do if like if I'm taking a pill and it's like this is going to reduce my risk of stroke by 80%. Do I have to understand the mechanism? No, I'm going to take it. But something about, you know, the fact that this is affecting our brain makes us intuitively a little bit more worried.
I mean, I think the brain is more of a black box and certainly amongst the organs, we understand it the least and we have the least amount of visibility into it.
I also think that people feel that who they are is located in their brain. And this anxiety that people have, I think that's quite understandable that if I take something that changes how I feel, does that change who I am? Or does that change aspects of myself that I don't want to change? And you don't feel that way generally when you're prescribed a high blood pressure medicine. I wanted to ask you Dr. Rostain when we're talking about efficacy, talk therapy is also effective and we think it works in similar ways. Right.
Well, I'm glad you brought that up because first let me emphasize I think the ambivalence that humans feel about taking a medication that affects their brain is a healthy thing. We should always ask, is this the right thing to do? Am I pleased or not with the results? And if I don't like what's happening, I better tell somebody about it. Because patients vote with their feet. They'll stop taking these meds if they don't like the way they feel or if they feel that the long-term effects are not what they're looking for.
It's very hard to get access to therapy. Our mental health system is in crisis. Mental health in general in the United States is not in great shape right now. But the ability to get that therapy makes it really unbelievably challenging for patients who don't have good insurance or who don't live in cities where there are therapists. And so the tendency of most of us would be to say, well, let's get you started on this medication. But I see this a lot in child psychiatry and pediatrics. We always recommend therapy because therapy actually works better and has longer-term effects on people's mood and anxiety.
So that's where I would agree with the comment you made that if the goal is to be able to manage one's emotional states more effectively then meds alone generally don't do the job and I always say that to patients, listen, I can start you on this medication, we really need to talk about how are you living your life, what can you do to feel better? Behavioral activation is probably more effective than most medications.
What do you mean when you say behavioral activation?
Getting up every morning and doing something, moving your body, exercise. I mean, incredibly powerful studies show that if you get up every day when you're depressed and you start exercising, your mood improves. And if you do it preventively, people are less likely to get depressed just because moving your body is good for your brain.
Right. There's sort of famously studies about the benefits of dancing being sort of as potent as some of the SSRIs, right? But as you're saying there, I think there are two things. One is it's easier to get access to the person who can prescribe the pill than it is to get access to the clinician who can prescribe ongoing meaningful therapy or provide it. Right? And then the other thing is that the pill is the pill. Therapy is an incredibly variable intervention. Right? And its efficacy depends so much on who's delivering it, the modality that they're delivering, whether you're doing something that's psychodynamic or whether you're doing something that's more cognitive behavioral therapy or you know whatever.
And the commitment of the patient.
The commitment of the patient, the relationship between the patient and the provider, all of those things. So it's one of the things that I think gets really murky here is we talk about categories of interventions as though they have sort of inherent benefits when actually there's a ton of variability across therapeutic relationships around what you're actually getting.
