Antidepressants are widely used and have helped millions of people – but they are still something of a puzzle in modern medicine. Despite decades of research, scientists are still debating exactly how they work, why they help some people and not others, and what their long-term role should be in treating depression.

To understand the uncertainty, imagine you have a headache, and I say, “Here, take these tablets. They should sort you out. At least they might … although I must mention they don’t work for everyone. I suppose I should also tell you about some of the possible side-effects … although they are not very common, I’m told. Side-effects include nausea, headache, difficulty sleeping, low libido, erectile dysfunction, weight changes, dry mouth and increased anxiety or agitation and lastly, but not leastly, suicidal thoughts, especially in young adults during early treatment. But take them, and I’m sure your headache will soon be gone.”

I bet you wouldn’t exactly be gasping to try a couple, but would rather stay with the headache.

That comparison isn’t perfect, but it captures the complexity of how many people feel about antidepressants.

The use of SSRIs

The most commonly prescribed antidepressants are called Selective Serotonin Reuptake Inhibitors (SSRIs), and they can, apparently, ease symptoms of moderate to severe depression. These include well-known medications such as fluoxetine and sertraline.

Approximately 13% of US adults take antidepressants, with SSRIs being the most common type. Over 10% of people in the United States and many other countries use these medications for mental health conditions.

SSRIs work by affecting a brain chemical called serotonin, which helps regulate mood, sleep, and emotional responses.

Serotonin is one of many chemical messengers in the brain called neurotransmitters. Neurotransmitters carry signals between nerve cells in the brain, called neurons.

After carrying a signal between brain cells, serotonin is taken back into those cells; a process called reuptake. SSRIs block this process, leaving more serotonin available in the brain to help pass messages between brain cells.

SRIs are called selective because they mainly affect serotonin, not other neurotransmitters. (SSRIs may be used to treat conditions other than depression, such as anxiety disorders.)

In simple terms, they aim to boost communication between brain cells in ways that may improve mood.

Do antidepressants work?

The short answer is: sometimes.

They may work in some circumstances – like my headache pills,  but they are definitely not for everybody.

Research shows that SSRIs can be helpful, particularly for people with moderate to severe depression. However, while some people may experience improvement, others feel only a small benefit, and some feel no improvement at all

And no, they do not cure depression, and they have the highest relapse rate of any treatment for what, essentially, is a mood disorder. They may make it easier to manage your mood/depression but they are definitely not a cure. (There is no consistent evidence of an association between low serotonin and depression.)

There is ongoing scientific debate about the idea that depression is simply caused by a “chemical imbalance”, such as low serotonin. Many researchers now believe depression is more complex, involving a mix of biological, psychological, and social factors.

If you believe there will ever be a drug which can cure depression, then you will also believe there will one day be a pill that will cure racism, poverty, domestic violence and pickpocketing.

Ok, so they don’t seem to be a magic bullet, but surely they are better than not taking anything?

Know about the side effects

Like most medications, SSRIs can have side effects, including:

• Nausea
• Sleep disturbances
• Reduced libido
• Weight changes
• Increased anxiety (especially early in treatment)
• Suicidal ideation (particularly in younger people)

The last one, about suicidal thoughts, is something you couldn’t make up. So Big Pharma who make SSRIs, expect people who are struggling with life, and finding almost everything pointless and horrible, have to contend with the very real possibility the drug they are taking to cure their condition, can actually be a contributing to the risk of them wanting to kill themselves – which is why doctors usually monitor patients on antidepressants closely when starting medication.

While it is important to note that not everyone experiences side effects, would you willingly take a drug with all those (possible) side effects if you had a stomach ache, or a sore throat, or the flu … or a headache?

When I was put on antidepressants before ending up depressed, I certainly never felt like they were helping me feel better. In fact, it took all feelings I had about anything away. I was just a huge, unemotional lump moving between activities. Eventually, I decided it was better to feel sad or at least something, rather than ‘flat-lining’ as I called it. So I got rid of the meds. (Fortuitously, at the time, I had an epiphany about depression.)

Other approaches

The more I delve into academia, the more I find similar opinions expressed by a wide array of professionals. One that seems to top the agenda on everybody’s ‘cure’ list is exercise. In dozens of videos I have watched on depression, the phrase, exercise is medicine is expressed with almost religious fervour.

So exercise is medicine, as effective as, or more so, than SSRIs, but has a lower relapse rate, being itself addictive; in fact, it has the lowest relapse rate of any of the ‘remedies’. Anyone who has got into long-distance running will recognise the high that comes from running due to the release of endorphins. This is very similar to the general exercise-induced euphoria people experience when training, and that ultimately induces them to exercise regularly.

Regular physical activity can:

• Improve mood
• Reduce anxiety
• Lower relapse rates

Other topics that aren’t as prolific, but certainly crop up constantly, concern themselves with self-esteem, self-confidence, and self-image.

In fact, many experts now view depression not only as a biological condition, but also as a social and psychological one, shaped by life circumstances, stress, and environment.

More and more, the general definition of depression is that it is a social disorder, rather than is so often touted, a chemical imbalance. If there is a chemical imbalance, it is just as likely caused by depression, not the other way around.

And there are therapeutic approaches that focus on:

• Self-esteem
• Relationships
• Coping skills

Where does that leave us?

The more I read, observe and have experienced concerning depression, the more convinced I am that, as are an overwhelming number of psychologists and psychiatrists, depression is a social disorder.

Antidepressants are not a magic bullet – and may, in certain circumstances, be a metaphorical bullet.

Medicines cannot teach life skills, build relationships, or address the deeper causes of distress. While they can provide support for some people, especially for severe symptoms, many mental health professionals recommend a combined approach, including:

• Medication (when appropriate)
• Therapy
• Lifestyle changes like exercise
• Social support

A final thought

Depression is complex. There is no single cause – and no single cure. Long-term well-being often comes from a broader approach: learning how to cope, connect, and live in a way that supports mental health.

If there is one takeaway, it’s this: there is no one-size-fits-all answer – and that’s okay.