State of Mind

The Terrifying Prospect of a Republican War on Antidepressants

Pills spill out of a prescription bottle.
Photo illustration by Slate. Photo by Getty Images Plus.

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There’s a familiar rhythm to the responses to mass shootings. From those who oppose gun control, among the calls for thoughts and prayers are often allegations that the perpetrator was taking antidepressants—typically selective serotonin reuptake inhibitors, or SSRIs, like Lexapro and Prozac—with the insinuation that the medication made them do it. We saw it after Uvalde; we saw it after Highland Park. Most prominently, Rep. Marjorie Taylor Greene, Fox News host Tucker Carlson, and right-wing social media influencer Jack Posobiec have directly blamed shootings on the increase in prescriptions for SSRIs. They based this on an utterance from the Highland Park shooter that he was a “depressed drug user,” but (as with most of these cases) there is no information on whether he had a prescription for SSRIs or any other psychopharmacological intervention.  When a U.K. newspaper recently covered an academic umbrella analysis disputing the role of serotonin imbalances in depression, the comments ran over with anti-psychiatric responses to the story, including pharmaceutical conspiracy theories.

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These claims stem from an area of scientific discussion in the early ’00s. In a somewhat infamous early case, a patient taking Prozac (fluoxetine) went on a rampage killing eight people and then himself in 1989; his family blamed the incident on the antidepressant. In the years that followed, SSRIs became a major psychopharmacological treatment, and several public health analyses in the early- to mid-d’00s raised concerns about the prescription of SSRIs, particularly about side-effects including violence and suicidality (especially in patients under 25). As a result, the FDA adding a black-box suicide warning to SSRIs and shifting guidance within the psychiatric community on their prescription.

There are reasonable questions about whether the black-box warning was a good idea. Some say that the black-box warning is harmful because it discourages doctors and patients from using SSRIs when they may be the best course of action. I would argue that the purpose of the black-box label is to ensure patients and doctors are aware of and consider these risks, though the informed consent issue is outside of the scope of this discussion.

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But as with many such conspiracy theories, the politicians trying to blame people taking SSRIs for mass shootings are misunderstanding of the issue. Recent partisan endorsement of conspiracy theories and outright attacks on psychopharmacology (and SSRIs in particular) is roughly analogous to the problem we have seen around coronavirus vaccination. When basic standards of care are seen as a political partisan issue, people who are on the anti-medical side of the partisan divide are significantly less likely to get treatment and less likely to trust their own doctors and health care providers. But it is not just about trust between providers and patients.

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Now we need to worry anti-SSRI positions becoming policy.

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Adverse events for medical interventions are common. There’s a reason why prescription medications should be used with the supervision of a medical professional who keeps up with the literature on possible side effects. When used consistently with best practices, SSRIs are an effective tool in treating a range of psychiatric conditions, especially in combination with therapy (which provides the requisite oversight to address adverse events). There are reasonable concerns within the medical community about how and when to prescribe SSRIs, especially to patients under 25. But certain members of the GOP want to turn those discussions into fear mongering about the historical recognition of side-effects and turn shifts in labeling into a reason to defund and even actively disrupt the best standard of care available in mental health.

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There are people who will suggest that merely discussing this is itself fear-mongering, noting that the people who are coming out against SSRIs are themselves largely fringe GOP figures with very little influence on federal-level GOP policy. But we should look at the role which issues that started as fringe conspiracy theories now play in contemporary national-level GOP politics. Birtherism went from a looney conspiracy theory that the John McCain presidential campaign wanted to shut down, to an incumbent-killing strategy during the Tea Party wave; the “great replacement” went from a 4chan conspiracy theory to a winning GOP presidential issue.

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There are two ways to look at the current anti-medical posture of the conspiracy theory wing of the GOP as it applies to a wide range of issues across the spectrum of public health and mental health. The first is to examine conspiracy theories as a political strategy since the Tea Party wave of 2010 (including public health conspiracy theories about “death panels”); the second is to look at the more recent development of coronavirus-related public health conspiracy theories. Both of these are important to understanding how a Republican politician like Greene can go on Twitter after a mass shooting and baselessly blame mass shootings on commonly prescribed medications that can be effectively used to treat a range of conditions. However, GOP opposition to mental health funding long predates the conspiratorial turn of the party.

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In the ’60s and ’70s, Presidents Kennedy, Ford, and Carter pushed for substantial reforms American mental health, moving away from institutionalization and toward community mental health programs, culminating in Carter’s Mental Health Systems Act of 1980.

But then President Reagan was elected. Since the early ’80s, the GOP has used budget policy to justify cuts to public health services, especially mental health services. In his 1981 budget, Reagan allocated funding in block grants that allowed the states to use money however they wanted. Instead of setting up the community mental health programs, states redirected that money into the carceral system, and jails and prisons became major providers of mental health services in America. Reagan had a history of exercising this strategy as governor of California as well. That’s a glossy summary, but it’s relevant to recognize that GOP opposition to mental health standard care also comes out of GOP financial policy.

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Mental Health America’s 2021 survey report ranked Texas dead last in the country for access to mental health services, despite being among the worst states (44 out 51, DC included) for prevalence of mental illness. The report notes that the major shift in Texas was the number of patients who could not see doctors due to prohibitive costs.

Now, imagine conspiracy theories about psychopharmacology and the GOP preference for block grants merge. Under the Affordable Care Act, funding for prescription drugs under Medicare Part D was significantly expanded and includes access to some standard SSRI treatments. At least for now, the federal requirements of Medicare Part D require access to a range of SSRI and other psychopharmacological treatments.

But that could change. The GOP’s attempt to repeal Obamacare in 2017 would have, among other things, implemented block granting for Medicare (including and especially Part D, which covers medications). That would have returned administration of prescription drug programs to the states, allowing state-level legislators to change the list of approved drugs covered by their programs. If states then want to take that money for prisons and gay conversion therapy, then they’d be free to do that on a state level.

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Should that happen in the future, GOP-controlled state governments could adopt anti-psychopharmacology positions. That would mean either outright prohibiting the use of such funds for SSRIs and other standards of care in psychopharmacology or directing the funds to groups that do not provide the accepted standard of care in the field. This isn’t hypothetical; the GOP has utilized similar strategies in other areas of health care since the 1980s, from the refusal to fund evidence-based treatments for LGBTQ+ people during the gay panic of the Reagan era to the contemporary opposition to treatments that satisfy standards of care for transgender people in GOP-run states (especially in the southeast). GOP-led states did it with throughout the coronavirus pandemic, fighting over whether to fund ventilators and personal protective equipment and insisting that health care funds be directed to ineffective and even dangerous coronavirus treatments like ivermectin. We are seeing it now in GOP-controlled states after Dobbs, where state-level legislation regarding how to assess risk during missed miscarriages results in serious, dangerous delays in abortion access to women in dire medical situations. Those are the most publicly visible examples; a comprehensive list would consume this whole article.

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More pernicious still, even the moderate wing of the GOP has historically embraced the idea of block granting to states. That means even if the opposition to SSRIs were never to become a national issue on the scale of vaccine denial, the embrace of those conspiracy theories by less-notable state-level GOP politicians in a position to handle appropriation of mental health resources (already largely distributed through such block grants) would have a similar effect on outcomes. The result would be to drive down access to medical treatments that work for mental health.

Let me be clear: SSRI use doesn’t cause mass shootings; they are not even positively correlated. The countries with the highest per capita consumption of SSRIs (Iceland, Portugal, and Canada) all have far lower rates of mass shootings than the United States.
The GOP panic about SSRIs is an attempt to change the subject. It won’t address America’s mass shooting problem; it will just make getting adequate medical treatment harder for people in need.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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