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Essays
False Beliefs in Academic Psychiatry:
The Case of Antidepressant Drugs
Michael P. Hengartner, PhD
Zurich University of Applied Sciences, Zurich, Switzerland
Martin Plöderl, PhD
University Clinic for Psychiatry, Psychotherapy, and Psychosomatics, Paracelsus Medical
University, Salzburg, Austria
Antidepressant drugs are the mainstay of depression treatment in both primary and
specialized mental health care. However, academic psychiatry holds false beliefs about
antidepressants and we expose two of them in this essay. First, recent attitude surveys
conducted among psychiatrists and general practitioners have revealed that physicians
attribute antidepressants’ effects mostly to the drugs’ pharmacologic action and less so
to placebo effects. Second, academic psychiatry maintains that physical dependence to
antidepressant drugs does not exist and that “discontinuation symptoms” upon stopping
maintenance pharmacotherapy are benign and affect only a small minority of antidepres-
sant users. As we review in this essay, these beliefs are at odds with the scientific literature.
The largest and most comprehensive meta-analysis of antidepressant trials conducted to
date indicates that 88% of the drugs’ treatment outcome is accounted for by placebo effect.
Furthermore, physical dependence appears to be a serious issue, as severe and persistent
withdrawal reactions affect up to 50% of antidepressant users according to several studies.
Correcting false beliefs prevailing in academic psychiatry is needed and has important
implications for psychiatric training, continuing medical education, and practice.
Keywords: antidepressant; depression; efficacy; placebo; discontinuation; withdrawal
With the powerful support of the pharmaceutical industry, academic psychia-
try has advertised a neurobiological etiology of depression over the last three
decades (Lacasse & Leo, 2005; Read & Cain, 2013; Whitaker & Cosgrove,
2015). This close co-operation resulted in an increased public acceptance of both neu-
robiological explanations and psychopharmacological treatments (Schomerus et al.,
2012), and media portrayals of the biomedical model of depression and antidepressant
drugs as the preferred treatment have strongly increased from the 1980s to the 2000s
(Clarke & Gawley, 2009). People consume more and more antidepressants each year
(Ilyas & Moncrieff, 2012; Kantor, Rehm, Haas, Chan, & Giovannucci, 2015; Vilhelms-
son, 2013), but, unfortunately, it seems that the public did not benefit from this marked
increase of antidepressant prescriptions. Depression prevalence rates remained largely
unaltered (Jorm, Patten, Brugha, & Mojtabai, 2017), whereas the burden and disabil-
Ethical Human Psychology and Psychiatry, Volume 20, Number 1, 2018
© 2018 Springer Publishing Company
http:// dx. doi. org/ 10. 1891/ 1559- 4343. 20. 1.6
6
ity attributable to depression have even increased in the general population (OECD,
2012; Whitaker, 2005). As a consequence, for a few years psychiatry is facing grow-
ing skepticism towards the benefits of antidepressant pharmacotherapy (Antonuccio,
Danton, DeNelsky, Greenberg, & Gordon, 1999; Gotzsche, 2015; Hengartner, 2017;
Moncrieff & Kirsch, 2005). Ongoing issues include, for example, the reporting and
publication biases inflating the apparent efficacy of antidepressant drugs (Pigott, 2011;
Turner et al., 2008), the disregard of both antidepressant dependence and withdrawal
reactions (Fava, Gatti, Belaise, Guidi, & Offidani, 2015; Nielsen, Hansen, & Gøtzsche,
2012), and the dismissal of patient reports of drug-induced adverse events (Gibson,
Cartwright, & Read, 2014; Medawar, Herxheimer, Bell, & Jofre, 2002).
A remarkable example is provided by the conclusion of leading European psychia-
trists to their own survey on patients’ attitudes towards antidepressants (Kessing, Han-
sen, Demyttenaere, & Bech, 2005). According to this work, 57% of antidepressant
users agreed that it is difficult to stop antidepressants when you have taken them over a
long period of time, and 56% agreed that your body can become addicted to antidepres-
sants. Instead of taking these concerns seriously, the authors stated that a large portion
of patients have erroneous views and lack knowledge about antidepressant pharmaco-
therapy. This conclusion is disrespectful of the patients’ lived experiences. Given that
the study was published in a leading scientific journal, this also raises serious concerns
about the adequacy of the peer review and, accordingly, the views of both editors and
reviewers. The study was published in 2005, at a time when leading psychiatrists should
have known that stopping or interrupting antidepressant pharmacotherapy causes drug-
induced withdrawal symptoms (e.g., Michelson et al., 2000; Rosenbaum et al., 1998).
A more recent illustration was provided by the launch of the Council for Evidence-
Based Psychiatry (CEP) in April 2014. CEP was initiated to communicate evidence of
the potentially harmful effects of psychiatric drugs to the public. In an interview with The
Times, CEP cofounder Professor Peter Gotzsche detailed why he thinks that antidepres-
sants do more harm than good (see https://www. thetimes. co. uk/ article/ antidepressants-
do- more- harm- than- good- research- says- 80p8njbcxbd). This press release stirred a fierce
reaction from leading British psychiatrists published in The Lancet Psychiatry, where they
accused Professor Gotzsche of “irrational polemic” and “flawed statements” (Nutt, Good-
win, Bhugra, Fazel, & Lawrie, 2014). But is there really such compelling scientific evi-
dence to discount critical views as irrational and flawed? Considering the scientific flaws,
methodological biases, and conflicts of interest in mostly industry-sponsored antidepres-
sant trials (Melander, Ahlqvist-Rastad, Meijer, & Beermann, 2003; Moncrieff & Kirsch,
2005; Perlis et al., 2005; Turner et al., 2008), there certainly is good reason to question
the alleged benefits of antidepressants (Antonuccio et al., 1999; Hengartner, 2017; Pigott
et al., 2010).
Obviously, there is a heated debate about the merits of antidepressants, where academic
psychiatry defends its favorable position on antidepressants by discrediting critical views
as erroneous and unsubstantiated (see also Whitaker & Cosgrove, 2015, for a detailed
account of the underlying institutional corruption). As we will suggest in this essay, the
problem is presumably less with erroneous views expressed by patients and researchers
critical of psychopharmacological drugs, but rather with false beliefs held by academic psy-
chiatry and promoted by the pharmaceutical industry. To not further divide proponents
and opponents, we would like to stress that our critical reappraisal of antidepressant drugs
is not intended as a stigmatizing campaign against psychiatry, as, for instance, claimed
7False Beliefs in Academic Psychiatry
by Nutt et al. (2014), but as a sincere attempt to counter criticism against patients and
researchers who express opposing views. As long as drug-critical findings are dismissed as
false presumptions made by uninformed patients or conspiring antipsychiatrist movements
(see Nutt et al., 2014), there is no possibility to improve the acceptance and care of people
with severe mental health problems.
PHARMACOLOGICAL DRUG EFFECTS ARE OVERSTATED
Physicians substantially overestimate the pharmacological effects of antidepressants and
their benefits overall. For instance, in a recent attitude survey conducted at an academic
hospital in the United States, the 79 surveyed psychiatrists indicated that only 26%
of antidepressants’ effectiveness was due to placebo effects (Vijapura, Laferton, Mintz,
Kaptchuk, & Wolfe, 2016). In another recent attitude survey among 87 German physi-
cians (of whom 40% were psychiatrists), approximately 60% of a drug’s total effectiveness
was attributed to its pharmacologic action and 40% to placebo effects (Kampermann,
Nestoriuc, & Shedden-Mora, 2017). These beliefs contrast with the results of randomized
placebo-controlled trials (for a recent meta-analysis, see Cipriani et al., 2018), which sug-
gest that 88% of antidepressants’ short-term efficacy is attributable to placebo effects, and
only 12% to their pharmacologic action.1 For the sake of simplicity, we consider spontane-
ous remission some kind of placebo effect, but note that formally spontaneous remission
would fall under the concept of placebo response. That is, approximately 8–10 people
need to undergo antidepressant pharmacotherapy in order for one person to benefit from
such treatment relative to placebo (McCormack & Korownyk, 2018). Research further
suggests that this small effect size is inflated due to conflicts of interest and method biases
and that it is clinically insignificant in routine practice (Gotzsche, 2015; Hengartner,
2017; Moncrieff & Kirsch, 2005; Pigott et al., 2010). That is, psychiatrists substantially
overestimate a drug’s pharmacologic effect, and they clearly underestimate the importance
of placebo effects (Vijapura et al., 2016).
Moreover, 93% of physicians agree that efficacy is due to a drug’s pharmacological
effect, but only 81% agree that side effects are caused by pharmacological effects (Kam-
permann et al., 2017), suggesting that a drug’s desirable effect (efficacy) is more frequently
attributed to its pharmacologic action than a drug’s adverse effects. This is another false
belief given that drug–placebo differences are much larger for adverse events (risk ratio
for decreased libido, tremor, and nausea is 3.5, 3.2, and 2.5, respectively) than for efficacy
estimates (risk ratio for both response and remission is 1.4) in meta-analyses of randomized
controlled trials (Jakobsen et al., 2017). Such findings do not necessarily prove that the
risks outweigh a drug’s benefits, because patients might accept to endure adverse effects
such as nausea or sexual dysfunction even when the reduction of depression symptoms is
modest. However, it seems that patients do not consider the drugs to be helpful, as they
prematurely terminate treatment with antidepressants at the same rate as treatment with
inert placebo (Arroll et al., 2009; Cipriani et al., 2018). Thus, based on patients’ behavior,
the benefits likely do not outweigh the risks. Given that the effect size for sexual dysfunc-
tion is much larger than the drugs’ antidepressant action, others have argued that a more
accurate label for antidepressants would be “antiaphrodisiac medications” or “antisexual-
ity drugs” (Antonuccio & Healy, 2012; Gotzsche, 2015).
8Hengartner and Plöderl
Interestingly, the longer the time since graduation, the stronger psychiatrists believe in
a drug’s pharmacologic action and the smaller they perceive the importance of placebo
effects (Vijapura et al., 2016). These findings suggest that more experienced psychiatrists
(who more frequently are both in leading positions and members of expert groups) are less
considerate of the more recent developments in the scientific literature on antidepressants’
efficacy. In addition, although 96% of psychiatrists were familiar with the recent literature
questioning the efficacy of antidepressants, only 23% reported that these studies have
influenced their prescribing practices (Vijapura et al., 2016). These findings further raise
the issue why continuing medical education has not resulted in a more evidence-based
appreciation of placebo effects, given that meta-analyses have already shown at the turn of
the 21st century that the response to placebo accounts for at least 80% of antidepressants’
efficacy (Kirsch, Moore, Scoboria, & Nicholls, 2002). This finding, which corresponds to
an effect size of approximately d = 0.3, was replicated many times since by independent
research groups (e.g., Jakobsen et al., 2017; Rabinowitz et al., 2016; Turner et al., 2008)
and must be considered best available evidence. To be clear, we do not contend that
antidepressant drugs have no mental effects at all. Antidepressants are psychoactive drugs
that may alter mental functioning (Moncrieff & Cohen, 2006), the most common effects
including emotional numbing, depersonalization, drowsiness, and agitation (Goldsmith
& Moncrieff, 2011; Read, Cartwright, & Gibson, 2014). However, we contend that they
do not specifically treat depression symptoms, as their antidepressive action is poor and
clinically insignificant (Gotzsche, 2015; Hengartner, 2017; Moncrieff & Kirsch, 2005;
Pigott et al., 2010).
SEVERE WITHDRAWAL EFFECTS ARE NEGLECTED
Another important discrepancy between the scientific literature and prevailing beliefs
held among leading psychiatrists concerns physical dependence and withdrawal symptoms
upon discontinuation of antidepressant medication. Although withdrawal is a bothersome
problem for many long-term users, the issue is largely neglected in the scientific literature,
in routine practice, and in psychiatric training (Fava et al., 2015; Gotzsche, 2015; Nielsen
et al., 2012). It is not uncommon for patients who report antidepressant withdrawal symp-
toms to be dismissively told by their physicians that these symptoms have nothing to
do with the drugs, but rather are signs of their underlying mental health problem (Gib-
son et al., 2014; Medawar et al., 2002). Kessing et al. (2005) even stated that patients
experiencing difficulties in stopping antidepressants due to physical dependence have
erroneous beliefs about the drugs. Recently, 30 people, including patients, scientists, and
practitioners, lodged a formal complaint with the Royal College of Psychiatrists (RCP)
for misleading the public on antidepressant withdrawal and for burying inconvenient data
from their own research program (see http:// cepuk. org/ 2018/ 03/ 09/ patients- academics-
psychiatrists- formally- complain- president- royal- college- psychiatrists- misled- public- anti-
depressant- safety/). This complaint was a response to a letter in The Times published on
February 24, 2018, where RCP president, Professor Wendy Burn, and the RCP chair of
the psychopharmacology committee, Professor David Baldwin, stated that “[for] the vast
majority of patients, any unpleasant symptoms experienced on discontinuing antidepres-
sants have resolved within two weeks of stopping treatment.” Such claims have been made
9False Beliefs in Academic Psychiatry
before by many others (e.g., Haddad, Lejoyeux, & Young, 1998), despite a clear lack of
supporting evidence.
Research consistently shows that bothersome withdrawal symptoms, including mood
instability, irritability, brain zaps, dizziness, or fatigue, occur in up to 50% of all patients
upon both abrupt and slow discontinuation (Fava, Bernardi, Tomba, & Rafanelli, 2007;
Rosenbaum et al., 1998; Sir et al., 2005; for a systematic review, see Fava et al., 2015). In a
recent survey among almost 1,200 long-term antidepressant users, 62% had unsuccessfully
attempted drug tapering before. Of these, 97% experienced withdrawal, with 49% report-
ing severe withdrawal (Groot & van Os, 2018). In a comprehensive attitude survey con-
ducted among over 1,800 antidepressant users in New Zealand, between 12% (fluoxetine)
and 47% (paroxetine) of respondents reported severe withdrawal effects (Read et al.,
2014). A randomized double-blind placebo-substitution trial showed that 6% (fluoxetine),
30% (sertraline), and 36% (paroxetine) of patients with remitted depression experienced
substantial increases in depression symptoms within 5–8 days of treatment interruption.
Due to fluoxetine’s long elimination half-life, 5–8 days interruption is too short a period of
time for withdrawal symptoms to emerge (Chouinard & Chouinard, 2015). The results for
fluoxetine must therefore be interpreted with caution. According to another randomized
trial, 34% (sertraline) and 44% (venlafaxine XR) of patients develop moderate to very
severe discontinuation symptoms following drug taper (Sir et al., 2005). Finally, in a meta-
analysis of placebo-controlled, mostly short-term duloxetine trials, 54.9% of withdrawal
syndromes lasted longer than 2 weeks (Perahia, Kajdasz, Desaiah, & Haddad, 2005).
For a significant minority, withdrawal reactions are severe to an extent that the symp-
toms qualify for a drug-induced persistent postwithdrawal affective disorder (Belaise, Gatti,
Chouinard, & Chouinard, 2012; Chouinard & Chouinard, 2015). In the double-blind
placebo-controlled trial by Rosenbaum et al. (1998) in patients with remitted depression,
withdrawal reactions qualified as depression relapse in up to 27% of patients, and in the
naturalistic observational study by Fava et al. (2007), 15% of patients with remitted panic
disorder with agoraphobia developed a cyclothymic disorder after gradual antidepressant
discontinuation. It has yet to be clearly established for how long severe withdrawal syn-
dromes and drug-induced affective disorders persist, but available data clearly show that
the problem is much more serious than academic psychiatry is willing to admit. That is,
bothersome withdrawal reactions are quite common and there is no evidence that these
symptoms dissipate within 2 weeks in the vast majority of persons concerned (Fava et al.,
2015). Antidepressant withdrawal, therefore, is a serious public health issue that warrants
more research and adequate appraisal by academic psychiatry (Gotzsche, 2015).
THE PAST, THE PRESENT, AND THE FUTURE
As touched on above, many antidepressant users report that they feel addicted to the drugs
(Kessing et al., 2005; Read et al., 2014), and it has been shown that, phenomenologically
and conceptually, antidepressant dependence is almost indistinguishable from benzodi-
azepine dependence (Nielsen et al., 2012). As a reminder, for almost 20 years and until
the 1980s, academic psychiatry had firmly dismissed the idea that therapeutic doses of
benzodiazepines could cause dependence (Lader, 1991). Now, leading experts suggest that
benzodiazepines are more harmful than recreational drugs such as amphetamine, tobacco,
10 Hengartner and Plöderl
cannabis, LSD, or ecstasy (Nutt, King, Saulsbury, & Blakemore, 2007). The beliefs that
there is no physical dependence to antidepressants and that “discontinuation reactions”
are a minor problem that is easy to manage (Haddad et al., 1998), are a major medi-
cal concern, since so many patients seriously suffer from antidepressant withdrawal for
months and even years (Belaise et al., 2012; Fava et al., 2015). In view of the pervasive
disregard of antidepressant withdrawal by academic psychiatry, perhaps other professionals
must assume responsibility to help the many people worldwide who suffer from physical
dependence to antidepressants. For instance, in their letter to the New York Times, science
journalists Carey and Gebeloff (2018) provide a thorough overview of the withdrawal lit-
erature, enriched with statements from withdrawal experts and some case reports, showing
that many patients do not succeed in tapering off their drugs. Although academic psychia-
try still maintains that serious problems with stopping antidepressants affect only a very
small minority, after a careful examination of the database, Carey and Gebeloff (2018)
conclude that withdrawal is a serious problem that affects many long-term antidepressant
users who want to stop their medication.
We can only speculate about why antidepressant benefits are overstated while risks,
including withdrawal reactions, are persistently minimized in academic psychiatry. One
likely reason is that academic psychiatry (Fava, 2007; Whitaker & Cosgrove, 2015) and
medicine in general (Angell, 2000; Light, Lexchin, & Darrow, 2013) are unduly influ-
enced by the commercial interests of the pharmaceutical industry. The companies produc-
ing medical drugs not only have strong financial ties with academic departments and their
leaders (Anderson, Dave, Good, & Gellad, 2014; Campbell et al., 2007) but they also
have a profound influence on the content of medical journals (Lexchin & Light, 2006;
Smith, 2005). That is, research sponsored by pharmaceutical companies is more likely
to yield both positive results and favorable conclusions (Als-Nielsen, Chen, Gluud, &
Kjaergard, 2003; Lexchin, Bero, Djulbegovic, & Clark, 2003; Lundh, Sismondo, Lexchin,
Busuioc, & Bero, 2012). These problems concern not only medicine in general, but of
course also research on antidepressant drugs. The pharmaceutical industry systematically
inflates efficacy estimates through selective reporting and publication (Melander et al.,
2003; Turner et al., 2008) and underreports adverse events and harm (de Vries, Roest,
Beijers, Turner, & de Jonge, 2016; Ebrahim, Bance, Athale, Malachowski, & Ioannidis,
2016; Maund et al., 2014).
The medical profession, supported by the pharmaceutical industry, has long denied
benzodiazepine dependence, and the same seems to happen now with antidepressant
drugs (Gotzsche, 2015; Nielsen et al., 2012). The neglect of both placebo effects and
withdrawal reactions may be largely driven by the commercial interests of the phar-
maceutical industry. Therefore, more governmentally sponsored studies conducted by
independent researchers without financial conflicts of interest related to the industry
are needed. Moreover, psychiatric training and continuing medical education should
not be sponsored, or otherwise influenced, by the pharmaceutical industry (Fava, 2007).
Finally, it is worth noting that there are other economies of influence corrupting aca-
demic psychiatry, such as, for instance, the field’s adoption of the biomedical model
of mental disorders and the promulgation of pharmacotherapy as first-line treatment
option (Whitaker & Cosgrove, 2015). Such undue influences are only bypassed when
nonmedical mental health experts, such as nurses, psychologists, or social workers, are
allowed to participate in expert committees and to have a determining influence on
practice guidelines.
11False Beliefs in Academic Psychiatry
SUMMARY AND CONCLUSIONS
In this essay, we put forward that academic psychiatry maintains two false beliefs that
have far-reaching implications for the treatment of major depression. The first belief
implies that the efficacy of antidepressants is principally due to the drugs’ pharmaco-
logic action. However, the results of large meta-analyses have consistently shown that
almost 90% of a drug’s action is due to placebo effects and, hence, that their clinical
effectiveness is questionable (Hengartner, 2017; Moncrieff & Kirsch, 2005). The sec-
ond belief maintains that physical dependence to antidepressants does not exist and
that bothersome withdrawal reactions upon treatment discontinuation affect only a
small minority of patients for a very short time. However, studies have shown that
antidepressants can cause physical dependence (Nielsen et al., 2012). Furthermore,
severe withdrawal reactions occur in up to half of all users and in long-term users these
problems can be so persistent and serious that they qualify for withdrawal-induced
affective disorders (Fava et al., 2015).
We therefore contend that some of the most insistently held beliefs in academic psy-
chiatry clearly conflict with the scientific literature. This likely has a major impact on
current treatment practice with its strong reliance on antidepressant pharmacotherapy.
Only when the field acknowledges that the drugs’ efficacy in attenuating depression
symptoms is by and large a placebo response will alternative interventions such as psy-
chotherapy or exercise be recommended to patients more often as first-line treatment.
And only when the field acknowledges that long-term antidepressant use can cause
physical dependence and severe withdrawal reactions in many, if not most patients,
then there will be fewer prescriptions for often unnecessary long-term maintenance
pharmacotherapy. Academic psychiatry remains devoted to ethical principles such as
“first do no harm,” which is why we are confident that it eventually acknowledges the
arguments outlined in this essay.
NOTE
1. The recent meta-analysis by Cipriani et al. (2018), which is the largest and most
comprehensive to date, estimated the mean effect size to be d = 0.3. This indicates that
continuous depression scores overlap by 88% between drug and placebo group.
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lan.
Michael P. Hengartner, PhD, is a senior researcher and lecturer affiliated with the Zurich Univer-
sity of Applied Psychology. He teaches psychopathology, psychotherapy research, and biostatistics.
His main research interests are psychiatric epidemiology, public mental health, social psychiatry,
and psychosomatics.
Martin Plöderl, PhD, is a clinical psychologist and psychotherapist and currently affiliated with the
Department for Crisis Intervention and Suicide Prevention at the Christian Doppler Clinic, Para-
celsus Medical University, Salzburg, Austria. His main research focus is about suicide prevention
and suicide risk of sexual minority individuals.
Acknowledgments. The authors thank the many antidepressant users who shared their personal
experiences with them. This work conforms to the journal’s editorial policy and ethical standards
in medical research.
Correspondence regarding this article should be directed to Michael P. Hengartner, PhD, Depart-
ment of Applied Psychology, Zurich University of Applied Sciences (ZHAW), CH-8037 Zurich,
Switzerland. E-mail: michaelpascal. hengartner@ zhaw. ch
16 Hengartner and Plöderl
