Do you need to know who you’d be without antidepressants?

Your Mileage May Vary is an advice column offering you a unique framework for thinking through your moral dilemmas. It’s based on value pluralism — the idea that each of us has multiple values that are equally valid but that often conflict with each other. To submit a question, fill out this anonymous form. Here’s this week’s question from a reader, condensed and edited for clarity:

I’ve been on antidepressants on and off (mostly on) since I was in my late teens. I’ve struggled for years with depression and anxiety, and the medication has seemed to help. But I’ve often wondered what it would be like if I tried to stop. 

There’s still a lot we don’t know about how antidepressants work. How much of what I felt to be them “working” might have been a placebo? And I’m a very different person now than I was back then. What if I don’t need the medication anymore?

I feel pretty happy in general, way happier than I was in my teens. But I just can’t shake the feeling that I’m medicating myself unnecessarily, without great evidence to back up the decision. Do I owe it to myself to find out what it would be like to be off medication? Did I make a mistake going on meds so early without thinking about how difficult an offramp might be?

Dear Antidepressant Ambivalence,

You’re in good company: One in six adults in the US currently takes antidepressants, and many wrestle with this question. That includes me; I take an antidepressant for chronic anxiety. And the wrestling makes sense, because antidepressants come with a lot of unknowns — both scientific and philosophical.

I have no medical training, so I can’t give medical advice, and decisions about psychiatric drugs should absolutely be made in conversation with a mental health professional. But let me offer you some framing thoughts that might help you get situated in this confusing landscape. 

On the scientific level, we do have strong evidence that antidepressants are more effective than a placebo, though their effectiveness varies from person to person. On average, people are 25 percent likelier to feel better if they take the real drug than if they take the placebo.

But we’re not really sure why antidepressants work. The old “chemical imbalance” model, which proposed that depression arises because there’s not enough serotonin floating around in the brain, is not taken seriously today among experts. Instead, scientists now have other hypotheses, like the idea that antidepressants work by boosting neuroplasticity. But you’re right that there’s still a lot we don’t know. 

And then there are the philosophical uncertainties. Antidepressants shape our thoughts and emotions, which make up a lot of what we think of as the self. So they can raise big questions about identity, about who we “really are,” especially for those of us who’ve been taking them for years. 

Most psychiatrists, with their meager 20-minute appointments, fail to help their clients explore these deeper questions productively. Yet the questions are extremely important. 

The anthropologist Alice Malpass and her colleagues offer a useful framework for thinking about this. Based on a lot of ethnographic research, they report that managing antidepressant medication involves two interconnected dimensions. On the one hand, there’s the “medication career,” which consists of your decision-making about whether to take meds, how much to take, and for how long. On the other hand, there’s the “moral career,” which is about how you make meaning out of all those practical decisions. What story are you telling yourself about your condition? About yourself?

Notice that to Malpass, the moral career is a full half of the equation, and rightly so: We know that the meanings people assign to their medications feed into their treatment outcomes. So I think it’s important to tackle the moral dimension of your question head-on. You ask, “Do I owe it to myself to find out what it would be like to be off medication?”

I believe the answer is no.

A common trope in the discourse on antidepressants is the worry that taking psychiatric medication means you’re moving away from your “true self” or “true personality.” That leads some people to wonder if they’re failing that self by not seeing what they’d be like off the medication. But I don’t think any of us has one “true self.” We are always being shaped and reshaped by everything we encounter. 

When I consider my own identity, I don’t see one preexisting essence — I see myself being constantly co-constituted by the influence of my family and friends, by the articles and videos I encounter online, by the yoga and meditation I do, by the coffee I’m drinking as I write this.

If there’s no preexisting one true self, then you can’t “owe” it to that self to act in this way or that. 

Instead, your task is always to look forward — to choose what sort of self you want to become. That means weighing the pros and cons of each option life offers you, and picking the options that you believe, based on the knowledge available to you in the current moment, will move you closer to the version of yourself you wish to be. 

As the 19th-century philosopher Søren Kierkegaard once observed: Life can only be understood backwards, but it must be lived forwards.

So, no, I don’t think you made a mistake by going on meds as a teenager. “Mistake” implies a regrettable choice, but since you were making the choice that seemed best given the knowledge available to you at the time, there’s nothing you need to regret. Chances are the meds did help you feel better back then, even though they raise the tricky question of whether and how to consider an offramp now. (You know who should feel regret? The psychiatric establishment, which has failed to properly study how to safely wean people off these medications. That lack of research is outrageous.) 

It’s easy to imagine that if you hadn’t started meds as a teen, you wouldn’t have to deal with any tricky questions today. But as the psychiatrist Awais Aftab points out, that’s a fallacy:

Sometimes the patients I see start psychiatric treatment for depression, anxiety, ADHD, etc., for the first time in their 30s, after years of hesitancy. When the treatment works, a common emotion I hear in such situations is regret: “I wish I had started this medication 10 years ago.” While people on long-term antidepressants wonder, “Who would I be off these medications?” the unmedicated are not immune from what-ifs of their own. Who could I be if I were taking antidepressants? Could I be more functional, more productive, a better parent, or a better spouse? Would I have been less obsessive, less neurotic, or more assertive?

In other words, there are trade-offs either way. Ambivalence is a totally normal response to a situation like this — maybe even the most appropriate response. As Aftab writes, this ambivalence is simply “the moral cost of living in a world in which medical progress presents us with more and more choices, and by doing so, brings the full diversity of human values into play and generates dizzying varieties of uncertainties and trade-offs.” 

In the face of all these uncertainties, which make it impossible to know if being on antidepressants is the best possible choice in some objective sense, the best you can do might be to consider — in partnership with a mental health professional — how the trade-off is showing up in your own life: Are the benefits of being on medication most likely outweighing the costs?

Be aware that even if the answer is no, and even if you want to come off the medication, it’s not advisable to stop taking antidepressants abruptly or at a time of high stress; a professional can give you some guidance on how to taper gradually, which can lessen the chance of withdrawal struggles.  

The fact that some people experience severe withdrawal symptoms when they stop antidepressants has made some people wonder about dependence. So it’s worth noting that, although people can form a physical or psychological dependence on antidepressants, that’s not the same thing as “addiction.” The latter generally comes with several other features, including compulsiveness, turning away from social connections, and using a drug in larger doses even when it causes health problems. 

Still, I know some people hate the idea of being “dependent” on anything at all — even, yes, coffee. If you’re among them, you might find the American philosopher Harry Frankfurt’s ideas helpful. 

Frankfurt drew a distinction between first-order desires (what we want) and second-order desires (what we want to want). To Frankfurt, what distinguishes the situation of a person with an unwilling addiction to some substance is that they have a first-order desire that conflicts with their second-order volition — they want not to want the substance, but they find it too difficult to act on that second-order preference. 

When considering my own experience, I find this clarifying. I know I have a second-order stance about the kind of person I want to be: someone capable of being deeply present with others, being kind and patient, being creative and productive, and being (more often than not) delighted by life. And this, for me, translates into a first-order desire to take my medication because I think it’s helping me achieve that second-order desire. In other words, my desires feel aligned. 

Importantly, I feel capable of taking a step back periodically and choosing whether I want to continue taking the medication or whether I want to get medical support to taper or come off it. I recognize that the latter might be very hard, but it still feels within the realm of choice. So although I feel some ambivalence, like you do, it doesn’t keep me up at night. 

If your experience is different — if it does keep you up at night — then I hope you’re able to find a mental health professional who is sensitive to the importance of the “moral career” and can help you thoughtfully explore it.

Bonus: What I’m reading

• In light of this week’s question, I reread Lauren Oyler’s New Yorker piece about her anxiety. She explains that, despite her various symptoms, she’s never tried to get a formal diagnosis or go on psychiatric medication because “I do not want to have these problems that are notoriously difficult to solve, about which there is no professional agreement.”

• My mind is always spinning up a narrative about my life, and that storytelling tendency is so strong that I was surprised to learn, from the philosopher Galen Strawson, that some people don’t experience themselves narratively at all.
  
• This recent Aeon essay explains how Japanese philosophy thinks of the “self,” and argues that the tendency of Western philosophers like Descartes to believe in one true self has led to a messed-up view of ethics for the rest of us. A taste: “Western philosophers succumb to the temptation to hold on to a fixed notion of the self that exists independently of that uncompromisingly polyphonic world, so that we can somehow construct a universal theory of ethics through the self-referential universalisation of individual consciousness.”