All in the mind? Writer Tim Clare on the pros and cons of anxiety drugs

When I took my first antidepressant, I had no idea I was joining a war. Not a war against the extreme low mood, anxiety and panic attacks that periodically made my life unliveable, but one over the very meaning of human suffering, and who gets to profit from its treatment. Which is, you know, a lot – especially when just putting your trousers on feels like an achievement.

In researching my book, Coward: Why We Get Anxious & What We Can Do About It, I spoke with psychiatrists, neuroscientists, microbiologists, geneticists, child psychologists, immunologists, sports scientists and read more than 1,000 peer-reviewed papers in sports science, nutrition, brain development, animal testing, artificial intelligence and theology. Nowhere did I encounter as many accusations of incompetence, bad faith and outright lies, as I did when researching antidepressants.

When we talk about antidepressants, we usually mean SSRIs and SNRIs – that is, Selective Serotonin Reuptake Inhibitors and Serotonin and Norepinephrine Reuptake Inhibitors. They’re a bit like putting a lid on a saucepan so, instead of the steam billowing away, it condenses on the lid and drips back down into the pan, to heat the food again. In this analogy, the steam is the neurotransmitters serotonin and – in the latter case – norepinephrine, aka noradrenaline. Less serotonin gets reabsorbed post-release, so there’s more around to restimulate receptors.

That SSRIs and SNRIs do this is relatively uncontroversial. The question is: does increasing levels of serotonin and/or noradrenaline in the brain help a person feel less anxious?

Researchers have spent millions of dollars researching this, and the answer is a frustrating: possibly, sometimes.

Several studies looking at many hundreds of trials of SSRIs like sertraline show they perform better, on average, at reducing problematic levels of anxiety than giving someone a sugar pill and pretending it’s an antidepressant, or not giving them any help at all. But almost no one thinks serotonin is likely to be the whole story – not even the manufacturers of the drugs. Most information leaflets that come with such medications include a line like: “It is not fully understood how antidepressants work.”

This might sound like a damning admission, but to fully understand any medication that acts on the brain requires a complete model of how our brains work. Given the human brain is a reasonable candidate for the most complex thing in the known universe, it’s not surprising that we haven’t cracked all its secrets.

Still, it’s understandable that many people are concerned about taking medications when we’re not sure why they work. Also, for many people, they don’t. When it comes to generalised anxiety disorder, for every five to seven people who take an SSRI, one person will recover who would not have recovered without it.

If that number sounds a bit rubbish, it’s no more rubbish than many common medications prescribed to deal with high blood pressure, stroke and other common chronic conditions. But it’s unlikely to reassure sceptics.

I think the topic is fraught because people experience radically different outcomes from antidepressants. I’ve taken SSRIs that had no effect. I’ve also had them stop my anxiety like flicking a light switch. I wasn’t zombified, I didn’t feel like I’d had a chemical lobotomy – I was just calm, and I could get on with the everyday business of living a normal life, which, when you’ve been living with daily panic attacks, feels miraculous.

If you’re one of the estimated 60%-70% of people for whom medication doesn’t provide a remission of symptoms, it’s hard not to feel cheated, especially when the side effects and potential challenges of stopping the medication are very real.

A 2018 systematic review of 24 studies found more than half of people who attempt to come off antidepressants experience withdrawal symptoms. Half of those describe the symptoms as “severe”. These symptoms are commonly known as “discontinuation syndrome”. A piece in the British Journal of Psychiatry argued that makers of psychiatric drugs pushed the term “discontinuation syndrome” because they wanted to avoid the stigma associated with “withdrawal”.

This doesn’t necessarily imply sinister intent – every provider of mental health support tries to describe their services in the least stigmatising language possible – but there has been considerably less funding for research into how people taper off psychiatric drugs than for research into how effective they are in the first 6-8 weeks of use. While writing Coward, I made the mistake of stopping my medication cold turkey, without consulting my doctor. I felt fine for a couple of days, then all at once it was as if all my emotions had been turned up to 11. I felt a plunging despair, I cried a lot, and everything felt intense and horribly fragile.

Most GPs recommend tapering your dose, slowly reducing it over time with their supervision. This reduces the risk of adverse effects.

Our current drugs for treating severe anxiety aren’t great. But that doesn’t mean they’re useless, nor that they’re part of some multibillion-dollar conspiracy to make people anxious then sell them solutions that don’t work. Antidepressants work quite well – sometimes really well – for some people. For others they don’t. That’s the frustrating, nuanced truth.

Studies suggest that when people combine antidepressants with an evidence-based therapy like CBT, they’re more likely to recover than if they received either on its own. Even so, one neuroscientist I spoke to reckoned that, for 25% of people, neither works. So it’s clear we need to fund a wide range of evidence-based approaches to helping severely anxious people manage their symptoms.

Coward: Why We Get Anxious & What We Can Do About It by Tim Clare is published by Canongate (£16.99)