They helped my friend’: Antidepressants, patient preference and the pressure to prescribe

Julia is 22 and works on reception of a hotel. She has been to see you a couple of times with symptoms of depression. There is no clear external cause, but she says she is prone to intermittent low mood. She can feel flat a lot of time, and occasionally tearful. But she is still working, she can enjoy herself when she goes out with friends and she has no suicidal ideation or self-harm. You have suggested exercise, stopping alcohol, guided self-help and referral for CBT but she requests antidepressants because they have helped a couple of her friends. Would you prescribe an SSRI to her based on her preference?

One of the most eye catching recommendations from the 2022 NICE guideline for depression NG222, 2022 was to not ‘routinely’ offer antidepressants for people with less-severe depression but to ‘only offer it if that is the person’s informed preference’.  When we covered this guideline on Hot Topics back in 2022, it raised a lot of eyebrows. We, and you our delegates, questioned the recommendation as it essentially implied that all patients with any degree of depression could have antidepressants on demand. Was this an evidence-based application of shared decision making that prioritised patient autonomy, or was it a case of consumerism driving clinical decision making leading to over-prescribing, medicalisation and potential harm?

Since the guideline I have reluctantly prescribed SSRis to patients who, deep down, I really don’t think needed them based on their request. It always leaves me feeling uneasy. Like most drugs, we know we can expect a good initial placebo response which can create an initial false sense of efficacy which may not be maintained, whilst the patient is exposed to potential side effects including the increasingly recognised problems of sexual dysfunction and the problem of withdrawal reactions.   Recent papers suggest that 30-70% of patients on SSRIs may experience sexual dysfunction J Psychosexual Health 2026, and 15% suffer from significant discontinuation symptoms on stopping Lancet 2024. But despite this, and the other known side effects, requests to prescribe continue to be common with ‘They really helped my friend’ often cited as a reason. This dramatic cultural shift in attitudes to antidepressants is hard to overstate - 20 years ago you often had to try hard to encourage people with severe depression to at least give an SSRI a try, whereas now antidepressants have even become ‘trendy’ Guardian, Nov 2025 with influencers promoting them on Tik-Tok leading to the ‘memeification’ of depression. 

As a result of this increased patient demand, combined with lack of time and resources to encourage the uptake of non-pharmacological interventions, antidepressant prescribing continues to increase. A recent NHS report in 2025 reveals that we prescribed antidepressants to 7 million patients between October and December 2024. The reduced stigma around mental health compared to the past is definitely to be welcomed, but we have to wonder have we gone too far? For some people, have antidepressants become the default response to normal human feelings of sadness and distress? 

If the NICE guideline and the idea of prescribing antidepressants on request also makes you feel a little uneasy, then I would strongly recommend an excellent editorial in this month’s BJGP entitled ‘Should antidepressants be prescribed simply if it is the patient’s preference? Why NICE guidelines must be revised’ BJGP2026;76;7. This excellent paper strongly argues that the NICE guideline from 2022 misinterprets the concept of shared decision making in the clinical consultation. Shared decision making is not the same thing as ‘patient preference’ which bypasses clinical expertise, judgement and scientific evidence. The paper cites that there is no evidence of improved clinical outcomes for antidepressants based on patient preference, the evidence base for less severe depression is weak and if medication becomes the automatic response to feelings of distress this erodes patient engagement with the lifestyle choices and psychosocial interventions which may be more beneficial for long-term outcomes. The BJGP editorial states that the NICE guideline ‘risks inflating unnecessary antidepressant prescribing, escalating healthcare costs, undermining evidence-based medicine and exposing patients to avoidable and potentially long-term harms’  and must be revised.

I think this is a really important paper, and I would strongly recommend it as essential reading to all of us who prescribe antidepressants. Regarding Julia, I will now have more confidence to say no to a prescription and to strongly encourage non-pharmacological alternatives within the framework of a listening, supportive therapeutic relationship and continued follow up. Her preference should be heard and respected, but a prescription should follow only if it is informed by clinical expertise, judgement and science and not by anecdote, meme or Tik-Tok.