Photo credit: Christina Victoria Craft
Then she said something that almost no one with a platform in American medicine will say on the record: that what we are calling a mental health crisis is, in significant part, a crisis of overmedicalization. That millions of people were handed diagnoses and prescriptions without being told that the trials supporting those drugs lasted six to twelve weeks. Without being told that what they felt when they tried to stop wasn’t their illness returning — it was withdrawal.
Delano is the founder of the Inner Compass Initiative and the author of a forthcoming memoir, Unshrunk. She was first prescribed psychiatric medication at fourteen. She testified before Congress because the movement she has helped build — one that brought nearly two hundred people from across the political spectrum to Connecticut last December — has arrived at the moment when the question she is asking can no longer be dismissed as fringe.
The question is this: what is the evidence base for the theory on which sixty-one million prescriptions rest?
In July 2022, a team of researchers led by Joanna Moncrieff at University College London published an umbrella review — a systematic review of existing systematic reviews — in Molecular Psychiatry, one of the field’s most respected journals. The paper examined the evidence for the serotonin theory of depression: the proposition, widely understood by the public and routinely invoked in the clinical setting, that depression is caused by low serotonin levels or impaired serotonin transmission in the brain, and that selective serotonin reuptake inhibitors work by correcting this imbalance.
The review found no consistent evidence supporting the theory.
Across the six areas of evidence the team examined — serotonin levels and metabolites, serotonin receptors, the serotonin transporter, studies artificially depleting serotonin, gene studies, and an analysis of whether antidepressants affect serotonin differently in depressed versus non-depressed individuals — the evidence did not support the conclusion that depression is characterized by low serotonin activity or that low serotonin causes depression. Some studies found the opposite of what the theory would predict. Most found no significant relationship at all.
This was not a fringe publication. It was not a preprint. It was a peer-reviewed systematic review in a major journal, conducted by researchers at one of the world’s leading universities. Its implications, if taken seriously, would require revising the explanation given to millions of patients about why they are taking drugs they may take for years or decades.
The mainstream response was, in most cases, to explain why the review was less significant than it appeared.
The defense of current prescribing practice runs through several arguments that are worth taking seriously.
The first is that the serotonin hypothesis, in its crudest form, was already a simplification that most researchers had moved past. The argument is that modern psychiatry does not actually claim that depression is simply low serotonin, and that the Moncrieff review was defeating a position no sophisticated clinician holds. This is partially true. Researchers have for decades understood that depression is neurobiologically complex. What is also true is that the simplified version — a chemical imbalance, corrected by medication — is what patients are told, what pharmaceutical advertising has communicated for thirty years, and what the prescribing culture has been built around. The gap between what researchers privately believe and what patients are told is itself a problem, regardless of whether the sophisticated version of the theory survives scrutiny.
The second argument is that SSRIs work, and that their mechanism of action need not be fully understood for them to be legitimately prescribed. This is also a serious point. Medicine is full of interventions whose mechanisms were established after their clinical efficacy was demonstrated. Aspirin was used for decades before its mechanism was understood. The question of whether a drug works is separable from the question of why it works, and the answer to the second question does not determine the answer to the first.
But the clinical trial evidence on SSRIs is itself more contested than most patients know. The landmark 2008 meta-analysis by Irving Kirsch and colleagues, published in PLOS Medicine, found that when unpublished trial data submitted to the FDA was included alongside published trials — a body of data that had been selectively unavailable — the effect size of antidepressants over placebo was below the threshold considered clinically significant for all but the most severely depressed patients. The drug companies had submitted all of this data to the FDA as required. They had published the positive trials. The negative ones remained largely invisible until Kirsch’s team obtained them through Freedom of Information requests. The meta-analysis was challenged and debated, as it should be. Its core finding — that the benefit of SSRIs in mild to moderate depression, as measured in the trials on which approval was based, is modest and may not be clinically meaningful for most patients — has not been credibly refuted.
The prescribing rate for antidepressants in the United States has tripled since 1990. Roughly one in eight American adults currently takes an antidepressant. A significant portion of those people have been on the drugs for more than five years — well beyond the duration of any trial on which the approval was based, well beyond the period in which long-term outcomes were studied before the drugs entered widespread use.
What happens when people try to stop is poorly understood and insufficiently studied. The clinical guidance historically characterized discontinuation symptoms as mild and short-lived. Patients, researchers outside the mainstream, and an increasingly organized community of people who have experienced prolonged and severe withdrawal syndromes have been saying for years that this characterization does not match the clinical reality. In 2019, the Royal College of Psychiatrists in the United Kingdom revised its guidance to acknowledge that withdrawal symptoms can be severe and prolonged. The American equivalent has been slower to follow.
This is what Laura Delano testified about. Not that psychiatric drugs have no place in the treatment of suffering. Not that the people who prescribed them were acting in bad faith. But that patients were not told what they needed to know. That the information on which informed consent should have been based — the duration of supporting trials, the mechanisms of withdrawal, the evidence on long-term outcomes — was not provided. That the gap between what the evidence supports and what patients are told is large enough, and consequential enough, to warrant Congressional attention.
The distributional reality of antidepressant prescribing in the United States carries its own argument. The drugs are concentrated in populations with the least power to evaluate the evidence independently and the least access to non-pharmacological alternatives. One in three children in the foster care system is on psychiatric medication, according to the figures Delano presented to Congress. These are not children whose prescribing decisions were made with robust informed consent or robust evidence of long-term safety. They are children whose behavioral distress was interpreted through a diagnostic framework and treated with the pharmacological tools that framework makes available, administered under institutional conditions that prioritize management over investigation of underlying causes.
The argument against raising these questions is not, at bottom, about the science. It is about what happens if the questions are taken seriously by people who are currently taking medications they may need. The fear is that people will stop their drugs abruptly and harm themselves, and that the harm done by undermining confidence in psychiatric treatment will exceed the harm done by the problems the critics are identifying. This is a legitimate concern that deserves to be stated plainly rather than obscured by the reflex to defend the current prescribing culture. It is also a concern that assumes the only alternative to unquestioning acceptance of the current system is dangerous destabilization of the people inside it — which is precisely the framing that the informed consent argument challenges. People who are told the full picture, including the evidence on withdrawal, are better equipped to make safe decisions than people who are not.
The $335 billion spent on mental health through Medicare and Medicaid over the past decade, with no measurable improvement in population mental health outcomes, is a number that should provoke the same institutional response as any other large public expenditure producing no measurable return. It has not. It continues to scale. The prescribing rate continues to rise. The suicide rate has not declined. The question of whether the framework driving all of this spending is correct was asked, on the record, before Congress, two weeks ago.
Congress has heard stranger things and done less with more. But the fact that the question has now been asked at that level, by someone who lived inside the system and understood what she was saying, is a development worth noting.
Sources: Laura Delano’s Congressional testimony as reported by the Inner Compass Initiative (theinnercompass.org), April 2026. Moncrieff J, Cooper RE, Stockmann T, et al., “The serotonin theory of depression: a systematic umbrella review of the evidence,” Molecular Psychiatry, July 2022. Kirsch I, Deacon BJ, Huedo-Medina TB, et al., “Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration,” PLOS Medicine, February 2008.
American Life is independent, advertisement-free analysis. Subscribe to receive every article in your inbox.
