Can We Have a Better Conversation About SSRIs?

Why mental health is too complicated for headlines and talking points

I just need to get some words out about SSRIs.

I started working as a Psychiatric Nurse Practitioner in 2017. I was a baby NP and starting my first job in the world of mental health. I was so intimidated. This was my first role as a provider and I was swimming in uncharted waters.

I worked as a cardiac ICU nurse throughout my master's program. It was a five year, torrid love affair with the heart. Given some of the unrealistic expectations that facility had on nurses at the time (and still does based on the recent murder of a nurse in their parking lot), it was downright unhealthy and toxic at times but I was in love with the intensity and pace of cardiac ICU. Everyday was different, patients were sick, and I felt a sense of pride in seeing the positive outcomes for my patients. I was engaged and confident, in a position where every patient and situation taught me something.

And then I was in mental health.

For people who do not work in medicine, cardiac care and psychiatry are nothing alike. It's kind of like being raised Methodist and marrying into a non-denominational Christian family. There are similarities, but the culture, language, and perspective can feel completely different.

These specialties also have a complicated relationship with each other. Medications used in one area can absolutely create problems in the other. I quickly realized I had to challenge some of the rigid thinking I had developed in cardiac care while learning how ot approach patient care through an entirely different lens.

It was hard but damn did I learn a lot.

At this point and for context, I guess it's important to provide a little trivial fact about me: I have worked with the forensic and correctional health population since my first NP job. And I've never looked back.

Working in forensic and correctional psychiatry especially changed the way I think about mental illness. You stop seeing mental health as an abstract political debate very quickly when you spend your days treating real people in crisis, people with trauma, psychosis, addiction, depression, anxiety, bipolar disorder, and lives that often fell apart long before they ever entered a jail or prison.

Psychiatry also taught me something medicine does not always like to admit out loud: sometimes helping people is messy. And nowhere is that messiness more apparent than in the way we talk about mental health treatment.

Mental Health Has Enough Problems Already

Mental health disorders have always carried stigma, largely because people fear what they do not fully understand. The brain is complex, behavior is complicated, and uncertainty makes people uncomfortable. When discomfort meets misinformation, we often fill in the gaps with assumptions instead of understanding.

But mental illness is not rare, abstract, or theoretical.

We are in a genuine mental health crisis in the United States. More than 1 in 5 U.S. adults experienced a mental illness in 2022, representing nearly 59 million people. Roughly 21 million adults experience at least one major depressive episode each year. Around 20% of adolescents ages 12 to 17 experienced a major depressive episode in 2021. In 2023, the United States averaged one suicide death every 11 minutes.

Those are not culture war statistics. Those are real people.

And perhaps most concerning of all, nearly half of people living with mental illness still do not receive treatment.

One of the many challenges is that there are very few black and white answers in mental health. Sometimes medications help tremendously. Sometimes they do not. Sometimes side effects matter - and then sometimes the untreated illness matters more. Sometimes the right answer is therapy. Sometimes it is lifestyle changes. Sometimes it is medication. Most of the time it is some combination of all of it. Ultimately everybody is different with unique and individual treatment needs.

That nuance is why the current conversation around SSRIs feels so deeply off course to me. So when I hear sweeping rhetoric about SSRIs being uniquely dangerous or harmful to society, I honestly find it difficult to reconcile with what I have seen firsthand as both a nurse and a provider.

We should absolutely question medicine.

Medicine should evolve. We should constantly ask whether current guidelines are still safe and effective, whether new research changes how we understand a medication, whether additional therapies help or complicate treatment, and whether better options exist. That is how science is supposed to work. Good medicine requires curiosity, humility, and a willingness to keep learning.

What we should not do is allow that scientific process to become fearmongering that keeps people from seeking help.

And nowhere is that more dangerous than in mental health.

That reality is why the current public conversation around SSRIs concerns me so much.

We cannot claim to care about America’s mental health crisis while simultaneously spreading misinformation, stigmatizing treatment, and encouraging fear around evidence based care.

What makes the conversation even more confusing is that some of the same public figures criticizing SSRIs have also expressed interest in expanding research into psychedelic assisted therapies for conditions like PTSD and treatment resistant depression. To be clear, I support continued research into promising therapies under careful medical supervision. Science should continue evolving.

But it is inconsistent to promote curiosity about experimental treatments while stigmatizing one of the most extensively studied medication classes in psychiatry.

SSRIs are not perfect. No medication is. They carry risks, side effects, and important clinical considerations that deserve honest discussion. But decades of research also support their safety, effectiveness, and role in treating millions of people living with depression, anxiety disorders, OCD, PTSD, and other psychiatric illnesses.

Patients deserve these nuanced conversations about mental health treatment with their healthcare providers, not through sound bites, headlines, and fear based rhetoric masquerading as medical discourse.

What SSRIs Actually Are (and What They Aren't)

To understand the difference between science and rhetoric, let's talk about how SSRIs work. If you're already familiar with the science, feel free to skip ahead.

Quick disclaimer: When I was fortunate enough to have students follow me, one of my favorite books to recommend was Memorable Psychopharmacology by Jonathan Heldt, MD. I love this book. Heldt has a gift for breaking down psychopharmacology into manageable pieces of information that are easy to understand without sacrificing accuracy. I have referenced this book so many times that the pages are literally falling out of the spine.

A lot of how I explain SSRIs is a combination of how my brain processes information and how Heldt teaches the subject.

Let's begin.

SSRI stands for Selective Serotonin Reuptake Inhibitor. In truth, they work pretty much the way the name sounds. These medications help block serotonin from being reabsorbed back into the neuron that released it. That's the "reuptake" part.

Most of us have heard of neurons, but in the spirit of education, allow me to provide a little more context.

Imagine two cliffs separated by a ravine. One cliff is lush and green with a flowing water source. The other is dry and waiting for water. These cliffs represent two neurons. The ravine between them is the synapse, the space where communication occurs.

The water represents serotonin.

As the water flows from the lush cliff to the dry cliff, it nourishes the landscape and allows growth to occur. Once the water has done its job, it returns to the original cliff where it can be collected, recycled, and used again.

This is, admittedly, a very simplified explanation of neurotransmission, but the basic concept is similar. One neuron releases serotonin into the synapse. The serotonin interacts with the receiving neuron and is then reabsorbed so it can be reused.

SSRIs partially block that reabsorption process. Instead of all the serotonin being immediately recycled, some remains available in the synapse longer, increasing serotonin signaling between neurons.

One important point is that this does not mean depression is simply caused by a serotonin deficiency. The brain is far more complex than that. Scientists are still working to fully understand why SSRIs help some people. What we do know is that for many patients, increasing serotonin signaling can improve symptoms of depression, anxiety, obsessive thoughts, panic symptoms, and other mental health conditions.

In other words, SSRIs are not creating happiness. They are helping certain communication pathways in the brain work more effectively.

Now that we've covered how they work, let's talk about what SSRIs do not do. I think this is where a lot of the public conversatitno goes off the rails.

1. SSRIs do not create happiness - If you're miserable because your spouse left you, your child is sick, you lost your job, or life has generally decided to choose violence this week, an SSRI is not going to make you wake up smiling and singing Disney songs. Sadness is a normal human emotion. Grief is a normal human emotion. Stress is a normal human emotion.

2. SSRIs do not erase your personality - One of the most common concerns I hear from patients is that they are afraid medication will change who they are. In reality, many patients describe the opposite experience. They tell me they finally feel like themselves again. The depression, anxiety, panic, or obsessive thoughts had become so loud that they were drowning out everything else.

3. SSRIs do not cure trauma - Trauma is complicated. Depression is complicated. Anxiety is complicated. Mental health treatment is rarely one-size-fits-all. Medication can be an important tool, but it cannot replace therapy, healthy coping skills, supportive relationships, sleep, exercise, or addressing the circumstances contributing to someone's distress.

4. SSRIs are not appropriate for every diagnosis or every patient - This is one of the reasons I find some of the current rhetoric so frustrating. Good psychiatric care is not about throwing antidepressants at every problem and hoping for the best. It involves careful assessment, understanding a patient's history, evaluating risks and benefits, and choosing treatments based on the individual sitting in front of you.

5. SSRIs are not addictive in the way we typically think about addiction - People do not take an SSRI and become intoxicated. They do not spend their day chasing a serotonin high. They do not steal from family members to get their next dose of sertraline. Can people experience withdrawal-like symptoms if they stop some SSRIs abruptly? Absolutely. That is why we usually taper them. But that is very different from addiction.

The truth is far less dramatic than the headlines. SSRIs aren't a miracle but they aren't villains, either. They are simply a tool among many that can help some people live healthier, safer, and more functional lives.

The Problem with the Current Conversation Around SSRIs

There is so much to say about the opportunities for improvement in mental health. That is an article for another day. But creating a plan to wean people off of SSRIs is not where to start. The research is there: SSRIs are helpful for many people and many people depend on these medications for improved quality of life.

When public figures describe SSRIs as dangerous, unnatural, or harmful to society, those comments do not exist in a vacuum. They land in living rooms, doctor's offices, therapy sessions, and family conversations.

They land in the mind of the teenager afraid to tell someone they are depressed.

They land in the mind of the mother struggling with postpartum depression.

They land in the mind of the veteran with PTSD.

They land in the mind of the patient who finally worked up the courage to ask for help and is now wondering if they should feel ashamed for needing it.

Their treatments deserves more than a sound bite, and that's what I want to explore next. In part 2, we'll talk more about SSRIs, where they are incredibly helpful, signs where they may not be most appropriate, what to expect when taking SSRIs, and continue to debunk common myths that continue to shape public opinion despite decades of research. If we're going to have a conversation about SSRIs, we're going to have the whole conversation.