Podcast Summary: "Feeling Stuck on Antidepressants in Midlife? How to Taper Off Safely with Mark Horowitz, PhD"

Podcast: BETTER! Building bodies women can trust with Dr. Stephanie Estima
Host: Dr. Stephanie Estima
Guest: Dr. Mark Horowitz, PhD (Psychiatry researcher & deprescribing expert)
Release Date: March 23, 2026

Episode Overview

This episode takes a deep, evidence-based dive into the widespread use of antidepressants by women in midlife, focusing on why they are so commonly prescribed (sometimes as a response to life transitions like menopause), the effects—both positive and negative—of long-term use, and most importantly, how to safely taper off if you decide it’s right for you. Dr. Stephanie Estima and Dr. Mark Horowitz aim to de-stigmatize the conversation and provide practical guidance, challenging outdated narratives around chemical imbalances and empowering women with actionable information.

Key Discussion Points & Insights

1. The Prevalence of Antidepressant Use in Midlife Women

• Stats & Context:
  • "One in three women between the ages of 40 and 60 are on an antidepressant." (Dr. Horowitz, 00:00)
  • 70% of people will meet criteria for clinical depression or anxiety by age 45.
  • 56 million Americans are on antidepressants; 25 million for more than five years. (Dr. Stephanie, 01:56)

2. Misdiagnosis: Menopause vs. Depression

• Many women in midlife are prescribed antidepressants for symptoms related to menopause—not clinical depression.
• Symptom overlap is common due to hormonal and life changes (e.g., sleep issues, anxiety, life stressors such as divorce or bereavement).
• "Low mood, anxiety, all the kind of unpleasant emotions...have been highly pathologized and medicalized in our modern society." (Dr. Horowitz, 12:03)
• Pathologization is driven by pharmaceutical marketing and a checklist approach to diagnosis.

3. Debunking the Chemical Imbalance Theory

• The serotonin hypothesis has been debunked:
  "There is no robust evidence showing that people with depression have lower serotonin or any other chemical compared to normal people." (Dr. Horowitz, 00:00, 27:47)
• The myth persists due to pharmaceutical marketing and oversimplification:
  "If you ask the public now in America, 90% of them say that depression is caused by a chemical imbalance." (Dr. Horowitz, 31:09)

4. Short-term Relief vs. Long-term Consequences

• Antidepressants “numb” emotions—blunting both negative and positive feelings.
  • "It's not a targeted bullet that gets rid of just negative emotions. It gets rid of the entire range of human emotions." (Dr. Horowitz, 17:00)
• While helpful in acute crises, long-term use has significant risks, like emotional numbing, sexual dysfunction, cognitive impairment, and substantial weight gain.
• Weight gain: 30% become overweight, 30% of those overweight become obese with long-term use. (Dr. Stephanie, 02:30; Dr. Horowitz, 19:05)

5. Addiction vs. Physical Dependence

• Not 'addictive' (doesn't create craving or euphoria), but does cause physical dependence.
  • "If a drug is addictive, it means you want more of it, you crave it...That's addiction, and antidepressants do not do that. But much more important than that is physical dependence." (Dr. Horowitz, 34:24)
• Missing doses or stopping abruptly often causes withdrawal due to the brain's adaptation to the presence of the drug—not because underlying pathology has returned.

6. Withdrawal vs. Relapse

• "The confusion comes…people can feel that it’s very similar to relapse or a return of their underlying condition." (Dr. Horowitz, 42:22)
• Withdrawal can mimic original symptoms—especially psychological ones—leading to misdiagnosis and lifelong prescriptions.

Many Symptoms Are Withdrawal, Not Relapse

• If symptoms are novel, more severe, or appear during a reduction: it’s likely withdrawal, not relapse.
• Physical withdrawal symptoms include headaches, brain zaps, gut issues, and agitation (akathisia).

7. Safe Tapering: Principles for Success

• Tapering needs to be much SLOWER than most guidelines suggest.
• The “halve and stop” method is harmful for most long-term users—the drop from low doses is particularly drastic (“jumping off a cliff”).
• “Hyperbolic tapering”—reducing dose by about 10% of the most recent dose each month, often taking a year or more.
  • Smallest available doses from pharmacies are rarely low enough for a safe final taper.
• "If you come off over several months or sometimes more than a year, the issues are much less." (Dr. Horowitz, 48:59)
• Creative solutions for making micro-reductions (liquids, bead counting, DIY compounding).
• Success rates of 70-90%+ when using hyperbolic tapering among persistent, gradual tapers. (Dr. Horowitz, 59:21)

8. When—and Why—to Consider Coming Off

• Drugs were designed for short-term (6–12 months) use in most guidelines.
• Long-term use brings greater withdrawal risk, potential physical health consequences (stroke, fractures, early death, etc.).
• Evaluate:
  • Was it prescribed for a temporary crisis now resolved?
  • Are side effects (e.g., weight gain, cognitive issues) outweighing benefits?
  • Are you actually benefiting anymore? (Many experience “tolerance.”)
• Reframe withdrawal difficulty as a probable function of physical dependence, not “proof” you need the drug forever.

9. Starting the Conversation with Your Doctor

• Don’t wait for your doctor—they may be waiting for you to bring it up.
• Useful questions to ask:
  • "Do you know what a gradual taper looks like?"
  • "Can you prescribe a liquid version for micro-tapering?"
  • "How do you distinguish relapse from withdrawal?"
• Seek out providers knowledgeable about hyperbolic tapering.
• Resources: Outro Health (US), NHS deprescribing clinics (UK).

10. Supporting the Process

• Lifestyle factors help but can't replace a careful taper:
  • "Anything that makes somebody more stable, less stressed, happier is useful in coming off... But primarily, coming off slowly is the main thing." (Dr. Horowitz, 80:40)
• Practices like exercise, better diet, mindfulness, and therapy are valuable supports.

Notable Quotes & Memorable Moments

• “One in three women between the ages of 40 and 60 are on an antidepressant.”
  (Dr. Horowitz, 00:00)

• “Low mood, anxiety...have been highly pathologized and medicalized in our modern society.”
  (Dr. Horowitz, 12:03)

• “There is no robust evidence showing that people with depression have lower serotonin or any other chemical compared to normal people.”
  (Dr. Horowitz, 00:00; expanded at 27:47)

• “If a drug is addictive, it means you want more of it, you crave it...That's addiction, and antidepressants do not do that. But much more important than that is physical dependence.”
  (Dr. Horowitz, 34:24)

• “If you come off over several months or sometimes more than a year, the issues are much less.”
  (Dr. Horowitz, 48:59)

• "The first few milligrams are easier to come off and the last few milligrams are hellish to come off."
  (Dr. Horowitz explaining tapering, 51:57)

• "I think fundamentally...anything that makes somebody more stable, less stressed, happier is useful in coming off the drugs. But primarily coming off slowly, especially at the end, is the main thing.”
  (Dr. Horowitz, 80:40)

• "You sell cars with brakes. The idea that we're giving out medications that aren't easy to stop and that don't have plans to stop, to me is fairly unethical."
  (Dr. Horowitz, 68:02)

• “The advertising has been incredibly successful... If you ask the public now in America, 90% say that depression is caused by a chemical imbalance.”
  (Dr. Horowitz, 31:09)

• "There's no shame, there's no blame. This is all done with love. It is not calling you out. We are talking about how to intelligently allow your body to get off of these drugs…"
  (Dr. Stephanie, 02:10)

Timestamps for Key Segments

• 00:00 — Prevalence, chemical imbalance myth
• 08:10 — Misdiagnosis: Menopause vs. Depression
• 12:03 — Medicalization of normal emotional responses
• 19:05 — Long-term effects: weight gain, sexual dysfunction, memory impairment
• 25:21 — The serotonin myth
• 34:24 — Addiction vs. dependence
• 37:37 — Neurological mechanisms of dependence
• 42:22 — Withdrawal vs. relapse and the clinical trap
• 48:59 — Principles of safe tapering
• 51:57 — Importance of microscopic reduction (hyperbolic tapering)
• 59:21 — Success rates of gradual vs. rapid taper
• 61:43 — How to know if you’re ready to come off
• 68:02 — Need for a timeline to stop at the start of prescribing
• 77:14 — How to start the deprescribing conversation with your doctor
• 80:40 — Lifestyle support during tapering
• 82:45 — Resources and where to learn more

Actionable Takeaways

• If you are considering coming off antidepressants, do not rush.
  Hyperbolic tapering (reducing by about 10% of your current dose monthly) is recommended, often requiring compounding, liquid versions, or creative dosing.
• Recognize withdrawal symptoms for what they are:
  Most symptoms on stopping are withdrawal, not “proof” that you need to stay on the drug for life.
• Don’t wait for your doctor to initiate the conversation—come prepared with questions and advocate for a gradual plan.
• Support the process with holistic health strategies (exercise, diet, therapy), but know they cannot substitute for a slow taper.
• Seek out specialized providers (like Outro Health, UK NELFT clinics) if needed.

Final Thought

This episode provides a compassionate, science-backed roadmap for women questioning long-term antidepressant use—especially those entering or in midlife. The key is empowerment through knowledge and collaborative, gradual steps, not shame or blame. As Dr. Stephanie says, "It isn't about being perfect; it's about being better."