Selective serotonin reuptake inhibitors (SSRIs) are some of the most widely prescribed medications for depression and anxiety, but how well do they actually work?
Recently, Secretary RFK Jr. called for an investigation into SSRIs due to their black box warning for suicidal ideation and self-harm, sparking debate over their safety and effectiveness. Meanwhile, Senator Tina Smith of Minnesota pushed back, saying her personal experience with SSRIs was positive and warning against stigma.
But here’re the real questions:
Are we actually being honest about SSRIs?
Do they work the way we assume they do?
Are we properly informing patients about their risks, particularly their metabolic side effects?
The reality is, despite their widespread use, we still don’t fully understand how SSRIs work, and we cannot isolate them as the sole factor in mental health improvement.
This article breaks down the science behind SSRIs, their real-world effectiveness, their impact on metabolism, and why informed consent in psychiatric medication needs a serious upgrade.
How Do SSRIs Work? The Inconvenient Truth
SSRIs are designed to increase serotonin levels by preventing its reabsorption, with the assumption that higher serotonin leads to improved mood. This serotonin hypothesis is the foundation of SSRI treatment—but does it actually explain how these drugs work? Not exactly.
Emerging research suggests SSRIs affect multiple neurotransmitter systems, including dopamine, norepinephrine, and glutamate. They also have anti-inflammatory effects and impact the gut-brain axis. This means their actual mechanism of action is far more complex than just “boosting serotonin.”
We’ve seen this pattern before:
• Antipsychotics were once thought to work solely by blocking dopamine, but we now know they interact with serotonin and glutamate in ways we didn’t originally understand.
• Benzodiazepines were believed to be simple GABA enhancers, but newer studies show they affect cognition, emotional processing, and even gut health.
• Lithium, used for bipolar disorder, still doesn’t have a fully understood mechanism, despite decades of research.
So why do we assume SSRIs are different? Why do we treat them as proven solutions when history tells us that psychiatric medications often work in ways we don’t yet grasp?
Another consideration: most research for SSRIs (even the poor quality research) is for use of less than one year. Yes, less than one year. Folks often end up taking an SSRI for years, which in practice is truly not substantiated in research. It is completely irresponsible for a prescriber to endlessly fill scripts for patients without discussing the full picture of their medications. After the one year mark, SSRIs have shown to be no better than a placebo, in fact, often times they're worse.
The Problem With SSRI Effectiveness: Can We Ever Isolate the Variable?
One of the biggest misconceptions about SSRIs is that they are solely responsible for symptom improvement. Here’s the typical story:
1. A person starts taking an SSRI.
2. Over the next 6 months, they feel better.
3. They (and their doctor) assume the SSRI worked.
But what else happened during those six months?
• They started therapy and developed healthier coping mechanisms.
• They made lifestyle changes, like eating better, exercising, or improving sleep.
• They moved past a major life stressor that contributed to their depression.
• Time passed, and the natural resilience of the human brain kicked in.
The reality is, we can never isolate SSRIs as the only factor responsible for improvement. Yet, people—patients and doctors alike—fall into the trap of assuming the pill did all the work.
SSRIs may help some people, but attributing all improvement to medication is bad science and bad psychiatry. If we don’t acknowledge this, we risk overprescribing medications that might not even be the primary reason for recovery.
The Metabolic Side Effects of SSRIs: What Your Doctor Might Not Tell You
Psychiatric medications don’t just affect the brain—they affect the entire body. SSRIs, in particular, have serious metabolic consequences, which are rarely discussed with patients.
Common SSRI Metabolic Side Effects
• Weight Gain – Many people gain weight on SSRIs, sometimes significant amounts. Some patients put on 20–40 pounds or more. This isn’t just from eating more—SSRIs directly alter metabolic function and fat storage.
• Insulin Resistance & Blood Sugar Dysregulation – Some SSRIs increase the risk of prediabetes and type 2 diabetes by making the body less sensitive to insulin.
• Cholesterol & Triglyceride Changes – Long-term SSRI use can shift lipid metabolism, which may increase cardiovascular risks.
• Gut-Brain Disruptions – SSRIs affect serotonin receptors in the gut, which can alter digestion, appetite, and nutrient absorption.
Why Aren’t Patients Warned About SSRI Risks?
If a diabetes drug had similar metabolic health effects, doctors would warn patients upfront. But with SSRIs, these risks are often glossed over or completely ignored.
This is a failure of informed consent.
Patients should know that when they take an SSRI, they aren’t just changing their brain chemistry—they are altering their entire metabolic system, potentially for life.
Why Informed Consent in Psychiatry Needs a Serious Overhaul
The way psychiatric medications are prescribed today is deeply flawed.
Too often, patients are:
• Told SSRIs are safe and effective without being informed of major risks.
• Not given full transparency about metabolic effects.
• Led to believe SSRIs alone caused their recovery, when other factors were likely involved.
A truly ethical approach to prescribing SSRIs would include:
✔️ Acknowledging the black box warning for suicidal ideation.
✔️ Full disclosure of metabolic risks, including weight gain, insulin resistance, and gut health changes.
✔️ A clear explanation that we don’t fully understand how SSRIs work.
✔️ Acknowledgment that SSRIs may or may not be responsible for symptom improvement.
✔️ A holistic approach to mental health, where medication is just one part of treatment.
Instead, what happens? A patient walks into a doctor’s office, gets handed a prescription, and is told, “Try this for six months and see how you feel.”
That’s not informed consent. That’s negligence.
Are We Overprescribing SSRIs? It’s Time to Ask Hard Questions
If RFK Jr. wants to investigate SSRIs, good. We should be questioning them. Science isn’t about protecting old ideas—it’s about challenging them.
We need to ask:
• Are we overprescribing SSRIs to people who don’t need them?
• Are we ignoring metabolic side effects?
• Are we misleading patients about how much SSRIs actually contribute to their recovery?
• Are we failing to explore better, more sustainable mental health treatments?
The pharmaceutical industry, the psychiatric establishment, and even well-meaning doctors don’t want to have this conversation—but it needs to happen.
Final Thoughts: SSRIs Are Not a Magic Bullet
📣 Let me be very clear... none of this is an argument against SSRIs entirely.
They may help some people. But the way they are prescribed, explained, and defended needs to change.
✔️ We don’t fully understand how SSRIs work.
✔️ We cannot isolate them as the sole factor in mental health recovery.
✔️ They have serious metabolic consequences that patients aren’t warned about.
✔️ We must take a more honest and informed approach to prescribing them.
It’s time to move beyond blind faith in SSRIs and start asking better questions. Because if we don’t challenge our assumptions, we’ll never improve psychiatric care.
It’s time for psychiatry to get honest.
I'm happy to continue this conversation. Please reach out if you have questions, comments, or concerns.
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