Thinking About Antidepressants?
Deciding whether to start an antidepressant can be a big decision. You might be feeling low, flat, anxious or exhausted, and trying to work out whether medication could help, what the side effects might be, or if needing medication means you have somehow failed to cope. Not exactly what you feel like facing when your brain is already as foggy as Melbourne winters morning.
Antidepressants can be genuinely helpful for some people, and whether they are right for you is a decision to make with your GP, psychiatrist or other prescribing clinician, taking into account your particular circumstances, history and preferences.
What I offer here is a psychologist’s perspective: some research to help make sense of the bigger picture, some context around the very persistent “chemical imbalance” story, and an overview of the psychological and lifestyle supports that can sit alongside medication, or be worth discussing as part of your plan.
My hope is that this gives you a better starting point for those conversations, and helps you consider what might be contributing to how you feel and what the path to feeling better could look like for you.
Depression is real. The chemical imbalance story isn't.
The idea that depression comes down to a shortage of serotonin has been the go to method of simplifying the complexity of our neurobiology. It's a tidy story that's and it's easy to get our head around. The only problem is, well.... its not what the evidence shows.
A major review pulling together decades of serotonin research found no convincing evidence that depression is caused by low serotonin activity, or that antidepressants work by fixing a known chemical fault. That doesn't mean biology is irrelevant, or that medication doesn't affect mood, it just means the old explanation is too simple to be true. Read the umbrella review by Moncrieff and colleagues. The truth is, despite loads of research, we don't really know the exact mechanisms involved in depression.
What seems pretty clear, is that depression makes much more sense as a whole-person experience. Genetics, temperament, hormones, physical health, sleep, pain, neurodivergence, trauma, loss, loneliness, work stress, money pressure, relationship strain, caring responsibilities and well....life.. can all play a part.
That distinction matters because it changes what "treatment" even means. Frame depression as a broken brain and medication looks like the only sensible move. Understand it as something happening in a body, a nervous system, a life and a set of relationships, and the list of options gets much longer (and thankfully so does our ability to try other treatments).
Do antidepressants actually work?
The honest answer: they do seem to help some people, but the average benefit is modest at best, and the response is very individual.
Large reviews of randomised trials do find antidepressants outperform placebo on average for adults with acute major depression. The well-known network meta-analysis by Cipriani and colleagues found all 21 antidepressants studied beat placebo in the acute treatment phase. Read it here.
But "statistically better than placebo" isn't the same as "life-changing" for most people. An influential reanalysis of trial data submitted to the US FDA found the average difference between antidepressant and placebo groups was less than two points on the Hamilton Depression Rating Scale, a scale that runs from 0 to 52. Read that again... 2 points better than placebo on a 52 point scale. Read Kirsch and colleagues' analysis.
People tend to misread that finding in both directions. It doesn't prove antidepressants are useless. Averages flatten out the people who respond well, the people who get nothing, and the people who mostly get side effects. But it does mean you should be sceptical of anyone promising a simple, reliable fix for a complicated human problem.
Perhaps, the more useful question isn't "do antidepressants work?" but "what am I hoping this will help with, what else might it impact, and how will we actually know if it's working?".
Side effects are worth a proper conversation
This is the part that can feel a bit awkward to raise in a short appointment, particularly when you are already feeling out of sorts. But side effects matter. Not because everyone will have them, and not because they automatically mean a medication is the wrong choice, but because you deserve to know what you might be signing up for and what your options are if something is not working for you.
Some side effects settle after the first few weeks. Others do not. Sexual side effects in particular are common enough that they should be mentioned plainly: lower libido, difficulty becoming aroused, delayed orgasm or not being able to orgasm, and erectile difficulties can all occur. For a small number of people, sexual difficulties can continue after stopping; we do not yet have a clear answer about how often this happens. If sex, intimacy or feeling like yourself matters to you, which, rather inconveniently, it does for most people, it is completely reasonable to factor this into your decision.
Other common side effects include nausea (which can often resolve after a few weeks), appetite increases/weight gain, sleepiness or insomnia, and dry mouth. It can feel a bit like robbing Peter to pay Paul.
Some newer antidepressants are less likely to cause certain side effects so it is definitely an important conversation to have and may even be worth doing your own research before making the final decision with your prescriber.
What often gets missed: withdrawal isn't automatically relapse
Another important conversation to have before starting an antidepressant is often the one left until much later, how will stopping actually work?
Antidepressants aren't generally considered addictive in the way alcohol, opioids or benzodiazepines are. However, the body does adapt to them, and reducing or stopping can therefore trigger withdrawal for some people. That can look like dizziness, nausea, sleep disruption, anxiety, agitation, low mood, odd sensory sensations, flu-like symptoms, or a general sense of being emotionally unsteady.
The tricky part is that withdrawal can sometimes look very similar to the symptoms that led someone to start the medication in the first place. I have heard more than one client say that, as soon as they reduced their dose, the old symptoms seemed to come roaring back, so they resumed the medication because it felt like proof they still needed it.
That does not mean every difficult patch after a dose reduction is withdrawal; relapse is possible too. It does mean it is worth taking a closer look with your prescribing clinician, rather than assuming either explanation. The timing, the particular symptoms, how soon they appeared after the dose change, and what happens with further adjustment can all help make sense of what is going on. This clinical paper by Horowitz and Taylor explains the distinction well.
A word of caution: If you're currently on an antidepressant: please don't stop suddenly or change your dose without talking to your prescriber first. A gradual, individualised taper is almost always safer, and some people need it slower than others. Healthdirect has a solid Australian overview of antidepressants and stopping them.
Before or alongside medication: therapy for depression
Good therapy isn't just "having a chat about your childhood," though sometimes childhood is exactly where the useful thread is. It helps you see the pattern you're caught in, then gives you somewhere practical to work from.
For depression, that can mean:
spotting the thinking styles that deepen hopelessness: all-or-nothing thinking, harsh self-criticism, mind-reading, catastrophising
noticing avoidance and withdrawal, then using behavioural activation to rebuild small hits of connection, competence, pleasure and momentum
working with what's actually underneath the symptoms: grief, trauma, burnout, conflict, loneliness, chronic pain, neurodivergence, perfectionism, or a life that's stopped fitting
building psychological flexibility, the capacity to feel something difficult without letting it drive every decision that follows
steadying sleep and daily rhythm, because an exhausted nervous system reads the whole world as more threatening and less workable
Psychological therapies have a solid evidence base here. A major network meta-analysis found several approaches, including cognitive behavioural therapy and behavioural activation, are effective for depression, with benefits that can outlast the treatment itself. Read the review by Cuijpers and colleagues.
Sleep and exercise are not side issues
When depression or anxiety takes hold, sleep is often one of the first things to go. Poor sleep then makes the low mood, irritability and rumination worse. It is an efficient little feedback loop, and not in a good way.
Sleep hygiene will not cure depression, and “just get eight hours” is fairly useless advice to someone staring at the ceiling at 3 am. But a few basics can help:
Keep a reasonably consistent wake time, even after a bad night.
Get some outdoor light early in the day where you can.
Keep the bed mostly for sleep, rather than scrolling, working or arguing with your own thoughts for hours.
Limit alcohol, which tends to disrupt both sleep quality and mood.
Create a short wind-down routine that lets your nervous system know the day is actually over.
Exercise is another one of those suggestions that can sound vaguely insulting when you are depressed. “Have you tried going for a walk?” does not quite inspire the enthusiasm people seem to think it will. It may not be such a ridiculous suggestion, however. A large 2024 review by Noetel and colleagues found that walking or jogging, yoga and strength training can meaningfully reduce depressive symptoms, either alongside therapy and medication or as part of a broader treatment plan.
The goal is not to suddenly become one of those people who “woo” their way through a 6 am SoulCycle class, we really do not need another one of them. It is about finding a form of movement that feels realistic enough to keep doing. A short walk, some yoga or gentle strength work is a perfectly good place to begin, especially on the days when motivation has gone completely missing. A walk around the block may be all you can muster, but who knows? You might see a Labrador carrying a stick the size of a small canoe, and that alone could make it worth your while.
How Two Birds Psychology can help
At Two Birds Psychology, I work with adults dealing with depression, anxiety, burnout, trauma, grief, relationship stress and neurodivergence-related overwhelm. Therapy can sit alongside medication at any stage: before you start, while you're taking it, or while you and your GP or Psychiatrist work through a careful reduction plan.
There is no one-size-fits-all answer here, but you do not need to have your entire mental health sorted by next Tuesday either. Therapy can help you get clearer on what is happening, what needs attention, and what might make life feel a little more manageable again. So if you'd like to explore therapy with me in Bondi Junction or by telehealth, get in touch for a brief call to see if it feels right.
This article is general information, not individual medical advice. Please speak with your GP, or psychiatrist before starting, changing or stopping any prescribed medication. If you're at immediate risk of harm, call 000. Lifeline is available 24 hours on 13 11 14.
Sources and further reading
Moncrieff J, Cooper RE, Stockmann T, et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Molecular Psychiatry. Read online.
Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs. The Lancet. Read online.
Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLOS Medicine. Read online.
Horowitz MA, Taylor D. Distinguishing relapse from antidepressant withdrawal. British Journal of Psychiatry. Read online.
Cuijpers P, Karyotaki E, Ciharova M, et al. Psychotherapies for depression: a network meta-analysis covering efficacy, acceptability and long-term outcomes. World Psychiatry. Read online.
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