Is there a mental health crisis in the United States? If you’re an individual suffering from depression, bipolar disorder or other conditions, the answer is likely to be “yes.” For the nation as a whole, the answer is the same. The numbers don’t lie.
According to a 2023 report by Mental Health America, a respected nonprofit advocacy group founded more than a century ago, 21% of adults (50 million) had experienced a mental illness in the past year. The picture wasn’t much better for young people; 16% of them (2.7 million) had experienced at least one major depressive disorder in the past year.
The report exposes the main reasons for these bleak numbers. Millions of people needing mental health services can’t get them, either because they lack insurance, do not have access to providers or can’t afford the cost. Another contributing factor: only a tiny fraction of the 15% of adults who had a substance use disorder in the past year received treatment.
There is no easy fix for a complicated problem that also includes ongoing stigma surrounding mental health. Yet there are effective treatments. They include antidepressant medications.
For example, selective serotonin reuptake inhibitors, or SSRIs, are one important treatment for one of the most common mental health conditions, major depressive disorder. However, these medications took an uncomfortable turn in the media spotlight recently when some health officials leveled harsh criticism at antidepressants, claiming it’s tough to get off of SSRIs once you start using them.
It’s not unusual to hear “alarms about antidepressants and overprescribing,” said Dr. Andrew Novick, assistant professor of Psychiatry at the University of Colorado School of Medicine. He said questions about antidepressants surface regularly in the media and among the public.
To address questions about antidepressants and highlight the facts about SSRIs and other mental health treatments for major depressive disorder, we spoke with Novick and his colleague, Dr. Scott Thompson, a PhD professor of psychiatry.
What is major depressive disorder (MDD) and what distinguishes it from the general term ‘depression’?
“The term ‘depression’ is one that we commonly use to describe a mood we have of feeling low, and down and sad,” Novick said. “That’s something that everyone experiences.” It’s very different from major depressive disorder (MDD), which is a psychiatric illness, as opposed to a mood that people have, he explained.
“MDD can be differentiated from ‘depression’ by its severity as well as the scope of symptoms that a person experiences,” Novick said.
What are the symptoms of MDD?
Novick said a “constellation of symptoms” that last most of the day, every day, for at least two weeks define MDD. They include:
- Sadness and low mood
- Lack of interest or pleasure
- Difficulty concentrating
- Sleeping too much or not enough
- Feelings of guilt or worthlessness
- Thoughts of ending one’s life
“Individuals with MDD will often have a combination of those types of symptoms,” Novick said. He encouraged people who experience any or all of these issues persistently to discuss them with their primary care provider and seek help from a mental health professional.
How does MDD affect people?
That varies widely, depending on each individual’s circumstance. However, MDD generally causes individuals to isolate and withdraw from the world. As Thompson explained it, activities that would usually produce pleasure and satisfaction – enjoying a good movie or book or spending time with friends and family, for example – no longer do so.
A paper Thompson and Novick co-authored with other colleagues identified a “negativity bias” as a “unifying feature” of MDD. Individuals viewing day-to-day life through “a negative lens” have difficulty engaging with the world, they wrote.
“If things are not pleasurable, you are no longer willing to expend the energy to seek them out,” Thompson explained. “Your world shrinks. You stop communicating and hanging out with your loved ones and friends.”
What causes MDD?
There is no simple answer because multiple factors can come into play, Thompson said. “The best understanding is that many of the symptoms of MDD are due to changes in the wiring of the parts of the brain that are important for processing mood and reward.”
The wiring can be disrupted by many factors, including trauma, stress, genetics, nerve inflammation and substance misuse, but the result is the often debilitating symptoms of MDD that Novick and Thompson described.
What therapies do we have to treat MDD?
There is “a gamut,” Novick said, including various forms of medications and psychotherapy. More discussion of those two below. Patients who have failed to respond to first-line treatments might benefit from transcranial magnetic stimulation, electroconvulsive therapy and “advanced psychotherapies,” such as the FDA-approved drug esketamine, Novick said. He is also principal investigator for a trial of the psychedelic compound psilocybin to treat anhedonia (lack of pleasure) in patients who have not found relief from other depression treatments. Read this article to learn more about that trial.
How do these therapies work?
They work differently to treat the multiple causes of MDD and the effects that the condition has on different areas of the brain. The general idea, however, is that the treatments improve symptoms by promoting “neuroplasticity,” Thompson said.
What is neuroplasticity?
It’s the “intrinsic property of the brain” that allows us to learn new things throughout our lives, Thompson said. In different ways, therapies for MDD rewire the disrupted brain signals that cause its crippling symptoms. That allows individuals to “become ‘unstuck’ from negative thoughts, emotions and behaviors,” as Thompson, Novick and their co-authors explained in their paper.
What are the most commonly prescribed medications for MDD?
They are medications called selective serotonin reuptake inhibitors, or SSRIs, and serotonin and norepinephrine reuptake inhibitors, or SNRIs. They are used to treat people with moderate to severe symptoms, Novick said.
How do SSRIs and SNRIs work?
They change the actions of serotonin and norepinephrine, neurotransmitters in the brain that affect our mood, sleep and thinking and therefore have a powerful effect on our behavior, Novick said. The brain carries “reuptake pumps” that act like vacuum cleaners, “sucking up” excess serotonin and norepinephrine for recycling. SSRIs and SNRIs block these reuptake pumps.
Serotonin and norepinephrine act naturally to counteract the symptoms of MDD. However, Novick emphasized that depression is not necessarily caused by a deficit of serotonin. Nonetheless, SSRIs and SNRIs are effective in treating MDD in many patients because the increase in the levels of these two key neurotransmitters promotes neuroplasticity – thereby restoring the normal behavior of the circuits for mood and reward, Novick explained.
Are these antidepressant medications effective?
The evidence suggests that they are. For example, a 2024 report from the National Center for Biotechnology Information that analyzed data on SSRIs, SNRIs and another kind of medication, tricyclic antidepressants, concluded that 50 out of 100 people taking antidepressants notice an improvement in their symptoms. This is compared to 30 of out of 100 people who noticed improvement with a placebo.
Novick and Thompson acknowledged that original studies of SSRIs by their pharmaceutical manufacturers were flawed, and that they do not work for everybody. Those facts have “fed a subgroup who attack them,” Thompson said.
However, Novick noted that a mountain of studies have come to the same conclusion. For example, a systematic review of trials conducted on major antidepressants and published in The Lancet concluded that “all antidepressants were more efficacious than placebo in adults with major depressive disorder.”
“These drugs do actually separate from placebo and are effective in treating MDD,” Novick said. “And just as important, they do a better job than placebo at making sure people stay better and don’t relapse back into a depressive state.”
Is it true that SSRIs are addictive?
No. “It’s important to define what ‘addiction’ is,” Novick said. Addiction is generally defined by a loss of control with a substance – like heroin – that leads to compulsive use and makes stopping it extremely difficult, he said.
“With antidepressants, we do not see a tendency for compulsive use,” Novick said. “People don’t take them and say, ‘Oh, my gosh, that feels great. I wonder if I take two, maybe three, how that would feel?’ It’s just not happening.”
The effects of SSRIs do not mirror those of “substances of abuse,” Thompson added. “Those substances become the center of your life, to the exclusion of all other things. SSRIs restore your ability to engage with life. It’s very different.”
Even if they are not addictive, is it hard to ‘get off’ SSRIs?
It can be, if an individual who has been taking them for an extended period of time stops doing so suddenly, Novick said. That can lead to antidepressant discontinuation syndrome, which produces symptoms like nausea and insomnia. For that reason, it’s important for patients to work with their provider to gradually taper off taking the medications, Novick said.
He added that in weaning patients off SSRIs, providers also must be vigilant against a relapse of their MDD symptoms and suggest strategies to prevent that. For example, as patients reduce their medication dose, they might have extra psychotherapy sessions or increase their exercise.
Can SSRIs increase the risk of suicide in young patients?
Yes. In 2004, the FDA issued a directive to the manufacturers of antidepressants, including SSRIs, to include a labeling and boxed warning for an elevated risk of suicidal thinking and behavior in children and adolescents.
Those risks are real, particularly at the beginning of treatment, Novick said. He noted that organizations like the American Academy of Pediatrics issue guidelines for the safe use of antidepressants for young patients. An important one is that the medications should be started at low doses and monitored closely, he noted.
“What you find is that as children and adolescents are on the medications longer, the increased risk of suicidal thoughts and behaviors not only goes back down to where it was, it gets better, and we actually can prevent suicides,” Novick said.
The American Academy of Childhood and Adolescent Psychiatry noted in a medication guide for parents of children with depression that the risk of suicide posed by antidepressants is balanced by the risk posed by depression itself.
“Treating underlying depression in youth who are thinking about suicide is an important strategy, because antidepressant medications improve depressive symptoms, which is the best way to treat suicidal thoughts and behavior,” the authors wrote.
Can psychotherapy be used to treat MDD? If so, what types are commonly used?
Psychotherapy can be very effective for mild to moderate cases of MDD, Novick said. Two evidence-based types frequently used are cognitive behavioral therapy and interpersonal therapy. The general idea of the therapies is to help people identify patterns of “automatic thought” that influence their interactions with and responses to others and affect their moods and behaviors, Novick said. People whose MDD falls into the moderate to severe range often require and can benefit from both psychotherapy and medications, he added.
How does psychotherapy help with MDD?
“It’s a mental form of going to the gym,” Thompson said. “You go to a therapist, you establish what the problems are and you work on them every week.” Doing so “builds up the mental muscles that allow you to respond differently to triggering events,” he said.
For example, a person might perceive certain words or actions from others as antagonistic or critical and respond by avoiding contact and becoming isolated and lonely. But with therapy the individual can learn to identify those situations and develop different, more productive ways to respond. In short, the work focuses on taking advantage of the brain’s neuroplasticity by encouraging and embedding new ways of thinking.
“It takes time and effort, but you can come out with a stronger person on the other side,” Thompson said. “These therapies seem to have the ability to facilitate that process.”
I don’t have time or money for medications and therapy. Can’t I overcome MDD through the force of my own will?
It would be very difficult to do that because of the nature of MDD. “One of the difficulties for people suffering with MDD is that the ability to face one’s problems is very much impaired,” Novick said. For that reason, urging a depressed person suffering through bouts of insomnia, inability to engage with friends, apathy and other symptoms to “buck it up” or “get over it” is not very helpful. “If they could, they would, right?” he said. “Having MDD feels awful. It is no fun at all.”
Thompson expanded on the analogy between getting mental health therapy and going to the gym.
“We all know we need to go to the gym more and work out more, and we’d be healthier and happier if we did,” he said. Still, we may resist doing it alone, he acknowledged. “One of the strategies for getting around that is having a partner or paying for a trainer.” For a person struggling with depression, a therapist can fill that role, helping an individual “get over the hump” and do the things needed to get better, he said.
Where can I go for help if I can’t overcome my depression on my own?
“The first thing that needs to happen when people have a problem is to go to someone who can help them identify it,” Novick said. “No one should have to diagnose themselves.” Primary care physicians provide vital help for people struggling with depression, he said.
“Depression is something they see every day. They prescribe more antidepressants than specialists like me,” Novick said. “They are able to diagnose and provide resources for their patients. And just the action of going to a doctor who cares about you and has your best interest in mind is a kind of psychotherapy.”
Novick noted that UCHealth has invested heavily in behavioral health care. That includes building mental health teams in its network of primary care clinics around Colorado.
The integration of medical and mental health resources in clinics has an additional benefit, Thompson noted. “Chronic medical conditions and chronic and acute pain can be a big trigger for mental health problems,” he said.
It seems a stigma surrounding mental health persists. How can we overcome that?
In Thompson’s view, “the entire American medical system downplays mental health,” which has led to a shortage of resources and access to care, as quantified in the Mental Health America report and elsewhere. He stressed that it is important for people to understand that mental health does not stand apart from physical health.
“None of us would hesitate if our child was suffering from a physical illness to reach out to a friend for advice about who to take the child to for treatment or what kind of doctor to contact,” he said.
“The person who has diabetes would be criticized for not taking insulin,” Novick added. “We would criticize them for not doing what they are supposed to be doing to take care of themselves. Yet in some ways it’s the opposite of that with mental health.”
Far from being weak, people who seek help for their mental health issues are taking responsibility for themselves, their children, parents, coworkers and loved ones, Novick maintained.
“When you take the steps to get mental health help, that’s a sign of strength,” he said. “You’re doing something that is not only good for yourself, but also good for others.”
Both Novick and Thompson also stressed the responsibility of scientists, researchers and providers to disseminate accurate information about mental health to a sometimes skeptical and distrustful public. They summed it up in the conclusion to their recently published paper.
“In the end, communicating research is just as important as the research itself,” they wrote.