First, Make Some Money

Physicians who say antidepressants should be available over the counter are putting their own profits, and those of the drug companies they’re paid by, before their patients

Recently, in a piece for the medical website STAT, Harvard psychiatrist and professor Roy Perlis argued that antidepressants should be made available over the counter, without a prescription, in the US.

Perlis was prompted to voice this opinion, he tells us, by the FDA’s approval of norgestrel (Opill), a brand of oral contraceptive, for sale without the approval of a medical professional.

“This change,” he wrote, “reflects the drug’s safety and the public health imperative to ensure wider access to birth control.”

So why not antidepressants? Isn’t there a public-health imperative to ensure wider access to treatments for depression too?

After all, “These medications, which have been used in the U.S. for three decades, have repeatedly been shown to be safe and effective for treating major depression and anxiety disorders.”

The US has never been in greater need of depression treatments, Perlis adds, but access to mental-health services, and to psychiatrists, remains limited. The vast majority of antidepressant prescriptions are made by non-psychiatrists, mainly primary-care physicians, who struggle to provide the level of care for depression that they provide for other chronic diseases.

Perlis describes how it can be hard for people suffering from depression to speak about their symptoms. Many people are simply too busy to keep a doctor’s appointment, and besides, people with depression have trouble making and sticking to plans in the first place.

In further support of his position, Perlis says antidepressants clearly meet the FDA’s three criteria for non-prescription medication: they can be used for self-diagnosed conditions; they don’t need to be prescribed by a clinician; and they’re unlikely to be misused or abused.

The opinion piece generated an immediate backlash from doctors. Many accused Perlis of corruption, pointing to his extensive ties to Big Pharma, which were not declared in the opinion piece, as is customary.

“Why can’t this psychiatrist, who is calling for antidepressants to be sold over-the-counter, like aspirin, also declare his numerous drugs company ties at the foot of this very biased, harm-erasing article?” Tweeted Dr James Davies, associate professor of medical anthropology and psychology at the University of Roehampton, London.

It was revealed that Perlis has, at various points, received payments from AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline and Pfizer. All of these companies make antidepressants. Pfizer, notably, makes Zoloft, the most commonly prescribed antidepressant in the US, and Eli Lilly makes Prozac, the fourth. Perlis also has equity stakes in two companies, Psy Therapeutics and Circular Genomics, which are both creating novel diagnostic tools and treatments for anxiety and depression.

With companies like Pfizer and Eli Lilly, the basis for the charge of corruption is pretty obvious: These companies make and sell antidepressants. If people don’t have to get a prescription for antidepressant use, more antidepressants will be sold and these companies will make more money. Those payments to Perlis, and to other doctors who are making similar arguments will have been a very worthwhile investment indeed: a drop in the ocean compared to the potential boost to profits.

When it comes to Psy Therapeutics and Circular Genomics, the two companies Perlis has direct equity stakes in, the benefits of making antidepressants available without a prescription seem a little less obvious, but they’re there when you look.

Let’s consider Circular Genomics in closer detail.

Circular Genomics makes no bones about the fact that mental-health disorders are a massive growth field for medical companies. Visit the company’s website and you’ll be told at the top of the landing page that there are one billion people worldwide with mental-health disorders, many of whom lack access to proper diagnosis and treatment; that more than half of the US population will have a mental-health disorder during their lifetime; and that the estimated global economic cost of mental-health disorders will be $16 trillion by 2030.

The distinctive stake of Circular Genomics in this boom industry is in creating new diagnostic kits based on simple blood tests. These will allow it to “[reshape] the patient-provider relationship in healthcare.” This is a disruptive enterprise, plain and simple. The aim here is to bypass medical professionals altogether by selling accurate kits that anybody can use.

A type of molecule called circular RNA is used as a “robust biomarker” to indicate the presence of brain disorders like depression, with results that can be interpreted as simply as, say, a home pregnancy test. According to the company’s co-founder, Nikolaos Mellios, this will totally eliminate “trial and error”—i.e. human opinion as opposed to biological fact—from depression diagnosis. “Circular RNA is poised to redefine care,” he says.

So: imagine a world where people just take a quick home blood test to determine whether they need anti-depressants, then go direct to the pharmacy or store to pick some up if they do. That’s the world Circular Genomics is looking to create. And if the company does create such a world, that will mean enormous profits, a decent share of which will go to Harvard psychiatrist Roy Perlis—far more money than he will probably ever receive from Pfizer or Astrazeneca or Eli Lilly. This potential scenario totally escaped reporting on the brouhaha surrounding the opinion piece.

Critics of Perlis are right. The system of Big Pharma patronage imperils the entire medical enterprise as it has existed since the days of the ancient Greeks, with its primary focus on the benefit of the patient.

Recent research out of Yale has shown that 57% of all doctors in the US have received over $12 billion in money from Big Pharma in the last decade. The researchers behind the paper analysed data from the Open Payments Database, which was established in 2013 by the Physician Payments Sunshine Act. The Act requires medical product manufacturers to disclose to the Centers for Medicare and Medicaid Services any payments made to physicians or teaching hospitals.

Companies manufacturing pharmaceuticals and medical devices made over 85 million payments to physicians within 39 different specialisations. Orthopedic surgeons, neurologists and psychiatrists, and cardiologists received the most payments.

It’s hard not to reach the conclusion that physicians and medical professionals have abandoned their traditional oath of “First do no harm,” as laid down by the father of medicine, Hippocrates, and opted for a rather less noble commitment: “First, make some money.”

But it’s also worth considering some of the arguments Professor Perlis made in his STAT piece, because other people who aren’t quite so compromised by Big Pharma handouts and biotech share-options might make them too.

Let’s take the most direct line of attack. Despite what Professor Perlis says, there are very few reasons to believe that antidepressants are worth taking at all, with or without a prescription. A number of studies have shown that anti-depressants are scarcely more effective at improving mood than placebo. The improvement is so small that some scientists argue it doesn’t even exist.

Another problem is that access to these minimal benefits is also unevenly distributed among users. A large meta-analysis in the British Medical Journal, considering data from over 230 studies of anti-depressant use dating back to the end of the 1970s, showed that just 15% of users experienced an improvement they wouldn’t have derived from the placebo, with the remaining 85 percent gaining no benefit from their use at all.

Those we’d hope would benefit the most from taking antidepressants—sufferers of severe depression, comorbid anxiety, and suicidal thoughts—actually benefit the least. Most clinical trials of anti-depressants deliberately exclude these very people, resulting in misleading claims being directed at the main target consumers of these drugs.

As if to underline the failure of antidepressants to work as they should, for the people who need them most, scientists can’t even verify the dominant chemical explanation for depression. Still. After decades of study, in 2024 scientists are no closer to an actual proof that serotonin deficiency is the cause of depression. And yet doctors continue to prescribe selective serotonin reuptake inhibitors (SSRIs) on the basis that serotonin levels are the issue.

So if these drugs don’t really work, and we don’t even know why they don’t work, what about their safety? Perlis wants us to believe that antidepressants are as safe as aspirin or other over-the-counter drugs, but again, the evidence suggest otherwise. Half of all antidepressant users become dependent, meaning that it’s basically impossible to give the drugs up, and it’s well-established that withdrawal symptoms can be far worse than the user’s initial symptoms of depression. That includes suicidal ideation and actual suicide in some cases. A minor struggle with one’s mood can turn, with the aid of antidepressants, into feelings of suicidalness that some users will act upon.

These weren’t problems I had the last time I popped an aspirin.

Given that such a high proportion of users are now teenagers and young adults, there’s been a lot of focus recently on the sexual side-effects of antidepressants. In particular, on so-called “numbing,” where users suffer a total collapse of libido and even lose sensation in their genitalia. Sometimes, these side-effects can be irreversible, even when a user stops taking the drugs. The rate of prescription for erectile-dysfunction drugs is three times higher among former users of antidepressants than the general male population.

There are other reasons to be worried about the sexual effects of antidepressants. There’s emerging evidence, for example, that antidepressant use during pregnancy may be contributing to the dire fertility crisis being experienced across the Western world. Many women will continue to take antidepressants for the full term of their pregnancy, with the general advice being that the potential risks to the baby are far outweighed by the risks to the mother of lowering the dose or ceasing treatment entirely.

The results of a new study suggest that antidepressants might interfere with the proper development of male babies in utero, in the same manner as chemicals like phthalates, BPA and per- and polyfluoroalkyl substances (PFAS). The study shows that elevated levels of a natural growth factor called activin A inhibit the proper formation of the testes and prevent them from being populated fully with germline cells, which go on to become sperm in adulthood. And what causes significantly increased levels of activin A in pregnant women? Uterine infections, pre-eclampsia—and yes, you guessed it, antidepressants.

Since we don’t know exactly how many women take antidepressants during pregnancy, I’d suggest we find out, sooner rather than later.

Nobody can deny that depression is a massive problem in the modern world, and it’s only getting worse. The terrifying statistics for antidepressant use bear that out. People are suffering, in huge numbers, and they’re looking for help. They’re desperate. In some countries, the rate of antidepressant use is now more than 25% among adults. And it isn’t just antidepressants, either. In Scotland, where a full quarter of all adults take antidepressants, a further third of adults are now being prescribed drugs from five broad classes associated with mental-health issues, drugs like gabapentinoids, benzodiazepines and opioid-based painkillers.

If this is “normal,” if a full quarter of the population should need medication just to be able to bear the burden of daily life, then I’ve not seen a satisfying explanation for why that should be so. It wasn’t always like this.

Here’s my alternative hypothesis: One of the chief roles of antidepressants is to mask the real causes of why is life so unbearable for so many people today.

The fundamental truth is that we live our lives at odds with our nature, which has evolved over millions of years in conditions that could not be more different from those we inhabit now. We eat food that some scientists believe shouldn’t even be classed as food (processed and ultra-processed food). We move less and less. We suffer from chronic stress and sleep-deprivation, bathing ourselves in blue light from morning to night. Our environment—the food, the water, the air—is poisoned with toxic chemicals that disrupt our body’s natural hormonal balance.

Antidepressants, administered on the scale they are today, prevent us from addressing the root causes of our unprecedented ill health. And by doing this, they ensure the money continues to flow to Big Pharma, and to the bent physicians they keep in their pocket—to men and women who renounced their pledge to heal and instead made themselves accomplices to a world of near-universal sickness.