Australia’s soaring antidepressant use is forcing an overdue reckoning with the serotonin myth, overprescribing and the medicalisation of ordinary human distress, writes Professor Vince Hooper.
PROFESSOR Joanna Moncrieff has been telling anyone who will listen, for the better part of two decades, that the chemical imbalance theory of depression is a marketing slogan dressed up as neuroscience.
Moncrieff's 2022 umbrella review in Molecular Psychiatry, now downloaded more than a million times, concluded what the careful reader of the literature had long suspected: there is no consistent evidence linking serotonin to depression. None.
The reaction divides into two distinct camps: the relieved (“I knew it”) and the angry (“how dare you”). Both responses tell you something about how deeply the serotonin story is embedded, not as a hypothesis to be tested, but as folk wisdom about what it is to be human.
Australia ought to pay attention. We are not innocent bystanders in this drama. We are protagonists.
Recently, the Medical Journal of Australia published a paper by Katharine Wallis of the University of Queensland, Anna King and Joanna Moncrieff herself.
The title was polite: ‘Antidepressant prescribing in Australian primary care: time to reevaluate’. The contents were not.
Around one in seven Australians, 3.9 million people, 14% of the population, is now taking antidepressants. Among those aged 75 and over, the figure climbs to 26%. Women are prescribed at 1.5 times the rate of men. General practitioners write 92% of the scripts. And the prevalence keeps rising, by roughly a third over the past seven years. Sertraline and escitalopram, both selective serotonin reuptake inhibitors, now sit in the top ten drugs by defined daily dose per thousand Australians.
Nearly two million of us are long-term users. If even 2% suffer severe withdrawal and the real figure is plausibly higher, that is 40 thousand Australians trapped on medication they may have started for a passing crisis a decade ago.
The story of how we got here is, like most pharmaceutical fables, half science and half advertising. Selective serotonin reuptake inhibitors arrived in the late 1980s with Prozac, marketed on the elegant premise that depression was a chemical deficit which the drug would correct.
It was a beautiful story. It was also unfalsifiable in the way that horoscopes are unfalsifiable: vague enough to feel true, specific enough to sell pills. The drug companies did not invent the serotonin hypothesis, but they pushed it well past the point where the evidence could carry it. Patients absorbed the message and asked their GPs accordingly. GPs, time-poor and underwhelmed by the alternatives on offer, obliged.
Moncrieff's umbrella review did not claim that antidepressants do nothing. It claimed that the mechanism by which they were said to work, correcting a serotonin deficiency, is not supported by the data. That is a narrower and more devastating claim than the headlines made it. The 36 senior psychiatrists who lined up to attack her in Molecular Psychiatry in 2023 mostly conceded the point in their fine print while insisting the drugs work anyway.
Perhaps they do, for some, by some mechanism, sometimes. But the foundational story sold to a generation of patients, that they had a brain disease being corrected by a precision pharmacological tool, has been quietly retired by everyone except the people who took the pills, including me.
We have built a national system in which the cheapest, fastest, most institutionally rewarded response to a teenager in distress, a widow in her seventies, or a fly-in-fly-out worker on the brink of divorce is a serotonin reuptake inhibitor that will probably still be in their medicine cabinet in 2035. The PBS makes it affordable. The GP visit makes it convenient. The cultural script makes it expected.
The objection that this is “what patients want” deserves a sharper response. Patients want what they have been told works. If a woman of 75 has been on escitalopram since her husband died at 62 and no GP has had the time, training or courage to discuss tapering, her continued use is not a preference. It is path-dependence dressed up as autonomy.
The Australian Medical Association is finally beginning to acknowledge this; the Royal Australian and New Zealand College of Psychiatrists, rather less so. Neither has produced a deprescribing framework remotely commensurate with the scale of the problem.
None of this is a brief for stoicism, denial of suffering or the cancellation of psychiatry. Major depressive disorder is real, it kills people and for a meaningful subset of patients, antidepressants are genuinely lifesaving. The honest position is that they are also being prescribed, on this continent, at industrial volume to people whose distress is the predictable consequence of loneliness, grief, abuse, financial stress, chronic pain, insomnia or the simple human condition of being unhappy for reasons no molecule will resolve.
We have medicalised ordinary sorrow, then subsidised the medicine, then built an aged-care system in which a quarter of our oldest citizens swallow a pill every morning that no one can explain the mechanism of.
A word of caution is owed to anyone who reads this and feels a flicker of recognition. Coming off an SSRI is not a weekend project. The honest path, speaking from experience, having tapered off citalopram after 15 years by reducing to a single tablet a week over six months, runs through a sympathetic GP, a slow hyperbolic taper measured in months or years and the willingness to back off if the body protests.
Abrupt cessation can produce withdrawal symptoms severe enough to be mistaken for the return of the original illness and, on occasion, worse than it. Do not stop on the strength of an opinion piece. Stop, if you stop, in proper medical company.
What would a serious national response look like? Honest conversations between GPs and patients about what antidepressants can and cannot do. Properly funded talking therapies, not the ten individual Medicare-subsidised therapy sessions per year that the Better Access initiative grudgingly provides. A national deprescribing protocol with the resources to support people through withdrawal. Frank reckoning with the social drivers, loneliness, family breakdown and economic precarity that we have been treating with chemistry because the politics of treating them with anything else is too hard.
Moncrieff is not a heretic but a consultant psychiatrist who read the literature, applied the methods her colleagues taught her and reached an inconvenient conclusion. The chemistry was a story. The prescription is a habit. Three-point-nine million Australians deserve to know the difference.
Depression and anxiety are nothing to be ashamed of.
Professor Vince Hooper is a proud Australian-British citizen and professor of finance and discipline head at SP Jain School of Global Management with campuses in London, Dubai, Mumbai, Singapore and Sydney.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Australia License
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