Weighing Antidepressant Risks Against Benefits: With Ronald Pies, MD

Ron Pies, MD, shared that he and coauthor Roger McIntyre, MD, wrote their recent article to counter what they see as a wave of misinformation about antidepressants. Pies said the misinformation has come partly from senior officials within the US Health and Human Services, whose "comments about the risks of anti-depressants that were way out of proportion to the actual risks and really quite alarming" drew particular concern. He added that patient advocacy groups and patients themselves have also raised legitimate—if not always fully accurate—concerns about antidepressant safety and efficacy, concerns Pies said clinicians cannot simply dismiss even when they disagree with the conclusions being drawn. Antidepressant withdrawal syndrome, he said, has emerged as a particular point of contention, fueled largely by discussion on social media.

On efficacy, Pies said no mood disorder specialist would consider antidepressants dramatically or exceptionally effective—he described them instead as modestly but reliably effective, outperforming placebo despite a substantial placebo response, particularly for acute treatment of major depressive disorder and for relapse prevention.¹ He said the evidence is clearest for those 2 indications but grows less robust for long-term use, noting that gold-standard trials are lacking to justify the 5 to 8 years, or longer, that many patients now spend on antidepressants.

On risk, Pies said antidepressant risks are real but manageable, and that psychiatrists have grown more attentive to discontinuation effects—particularly with serotonergic agents—over the past 5 to 7 years, now favoring slow, careful tapering.² Still, he said "the issue of the severity and frequency of these withdrawal reactions has been overstated by some writers, some clinicians, and some of these advocacy groups." Pies said psychiatrists were slower than they should have been, historically, to recognize discontinuation problems, but that the pendulum has since swung toward greater caution around stopping serotonergic antidepressants.

Pies said the overarching goal of the article he authored with McIntyre is to help colleagues weigh antidepressant risks against benefits in proper perspective—acknowledging genuine safety concerns without overstating them, and acknowledging modest but real efficacy without overselling it.

Dr Pies is editor-in-chief emeritus of Psychiatric Times and professor emeritus of psychiatry at SUNY Upstate Medical University and Tufts University.

References

1. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Focus (Am Psychiatr Publ). 2018 Oct;16(4):420-429.

2. Fava GA, Cosci F. Understanding and managing withdrawal syndromes after discontinuation of antidepressant drugs. J Clin Psychiatry. 2019;80(6):19com12794.