The Stigma Around Psychiatric Medication Is Forcing People to Suffer In Silence
I sat on my porch cry-laughing reading Glennon Doyle's Untamed just the other day; I found myself choking on my morning coffee reading her 'hymn' in a chapter about mental health. "Jesus loves me, this I know, for he gave me Lexapro."
While this was incredibly validating for me (particularly because that aforementioned morning coffee had just washed down 150 milligrams of Wellbutrin), few people have such a comfort level discussing psychiatric medication.
Stigmatized as "crazy pills" and "addictive toxins," anxiolytics, antidepressants, and mood stabilizers have been given a bad rap, and subsequently branded their consumers with a stigma as well. But we don't see that kind of stigma around blood pressure medication, antiepileptics, or even painkillers.
Maja Stevanovich, founder of Braintuff, a mental health organization based in Milwaukee, was diagnosed with bipolar II and attention-deficit/hyperactivity disorder (ADHD) at 30, but because of the stigma around psychiatric medication, she didn't get the life-changing chemical rebalancing she needed for quite some time. Finally, she broached the topic with her doctor, facing her fear of using this type of medication.
"I had no idea this was the life I could live," says Stevanovich. "It immediately brought me relief and peace...and, frankly, a chance to breathe and do my work more efficiently." She had heard so much negativity around these medications and assumed she would "turn into a zombie" after taking the first pill.
There are plenty of "jokes" all over pop culture too — jokes dripping in condescension about people who are passed out from Xanax or comatose from Ativan. And of course, there's the misrepresentation in TV and movies.
"Many may think of One Flew Over The Cuckoo's Nest, Girl, Interrupted, or Gone Girl when we think of how mental illness has been portrayed in the media," says Kathleen Rivera, M.D., psychiatrist at Nuvance Health in New Milford, CT. "As a society, we often use media as a source of education. This has great advantages making knowledge very accessible, but also has its downfalls, as there is much misinformation." This can fuel the 'zombie' stigma that Stevanovich experienced.
Stevanovich overcame her own ingrained stigma, but she still faced judgment from those close to her. "With Adderall especially [for my ADHD], I had some friends accuse me of drug abuse — I confided in them, and their misinformation and thoughts on Adderall being a 'recreational drug' led them to pass judgment on me," she says.
Kevin Gilliland, Psy.D., a clinical psychologist in Dallas, believes some of this shame and misinformation exists because "not all diagnoses are equal." There's a hierarchy of sorts when it comes to how we look at different conditions. "People are more than willing to talk about their high blood pressure, but a lot less willing to talk about their STD; similarly, people have become more willing to talk about anxiety or mood issues but less likely to talk about addiction issues. That has to do with perception, bias, fear, experience, and at some level, stigma."
This stigma not only prevents people from seeking the mental health care and treatment they need in the first place, but also stops them from talking to their doctor about (or even considering) prescription meds, keeps them from filling that prescription, and stops them from taking it continually as prescribed.
There's more than just anecdotal evidence, either: Surveys (shared by the Centers for Disease Control and Prevention (CDC), American Psychological Association (APA) and published in The Mental Health Clinician — just to cite a few) find the majority of people have witnessed biased and negative views regarding mental health-related issues, or feel that way themselves. At the same time, if we actually treated these issues, our entire world (literally and figuratively) would improve, says Gilliland.
Where did this stigma come from, and why are we still dealing with it in 2020, when diagnoses (and prescriptions) for mental health conditions have increased exponentially? Because stigma, shame, and misinformation at large serve as massive barriers between patients and fundamental healthcare, we need to address this head-on to figure out what we can do about it.
The Origin of the Stigma
An Early Look at Mental Health
"The stigma [attached to psychiatric medication] likely originated before the 19th century, when there were limited biological treatment options for mental illness," says board-certified psychiatrist W. Nate Upshaw, M.D., medical director of NeuroSpa TMS in Florida. "With no great treatment options available, patients suffering from mental health problems were often stigmatized because they were likely to suffer chronic problems from their mental health issues and often had to be institutionalized."
Dr. Upshaw shared that although with the advent of psychiatric medications, patients who would have been institutionalized were able to improve and often return to normal functioning lives, the stigma didn't dissolve, particularly in the U.S.
"We have to look at how the mentally ill have been treated by society (including the medical society) in the past," says Dr. Rivera. This, "in addition to the many times that criminal behaviors have been attributed to mental illness, hence creating a culture of fear around the mentally ill and ignoring the scientific data that indicates otherwise."
Think about the 4,000-year history of telling women they have hysteria (for any range of symptoms) and prescribing marriage, sex, and even hysterectomies as treatment; giving general lobotomies to people with depression (a procedure that severs connections in your prefrontal cortex, i.e., cuts up your brain); sending patients with schizophrenia into insulin comas; and simply locking patients (then called 'lunatics') up in asylums — some of these examples (of which there are many more) still being practiced as recently as the 1980s.
Survival of the Fitt...ing In
"As much as our country prides itself on individuality, we [as humans] are hard-wired by nature to fit in and be part of a group," says Charles Herrick, M.D. of Nuvance Health, chairman of psychiatry for Danbury Hospital, New Milford Hospital, and Norwalk Hospital in Connecticut. Historically, anyone with a mental illness "behaved differently from the group," he explained, which could result in "banishment" from a tribe or pocket of society. This is why, from a survival standpoint, there's a drive to conform (and therefore hide any differentiator, such as mental illness). "This hard-wired need to fit in and belong — as a matter of survival — is critical to our understanding of why the stigma of mental illness developed and continues to exist," says Dr. Herrick.
People with different types of mood disorders or mental illness have been considered "alien" for a long time. "At the beginning of modern medicine, the conditions then recognized as mental illness — such as 'mania' and 'schizophrenia' — had behavioral signs obvious to most people who viewed them as forms of madness, and lead to hospitalization in asylums treated by doctors called 'alienists,' because they treated people who were alienated from their group," says Dr. Herrick.
Basically, those with mental conditions were largely left untreated, which led to their behaviors being drastically divergent from the 'normalcy' of their groups, which (as you might've guessed) then led them to be ostracized or banished from their groups. And as we're genetically programmed to 'need' our social circles for survival, we then interpret any kind of mental health issue as a fast track to losing everything. Having a mental condition threatened survival from a social standpoint.
Stigma doesn't just stem from our social circles — and it's not just a matter of being judged by peers. Some stigma is built into our societal structure.
Threat of Discrimination
"Receiving mental health treatment, including medications, can lead to [illegal] discrimination at work, with housing, and with insurance," says Dr. Upshaw. "Specific jobs require people to disclose mental health problems, and they may even go as far as requiring the patient's physician to list the medications the patient is taking; these rules are not always based on scientific evidence and can border on discrimination."
Discrimination against patients who need to take certain medication only serves to deepen the stigma and elongate the distance between 'health' and 'mental health,' when they're actually one and the same. Treating psychiatric medication differently than, say, an antispasmodic medication (used for IBS) or blood pressure medication, subversively yet powerfully keeps the world of mental health separate, and those who are in it feel othered; somehow different from every other patient receiving care for other types of health issues. This is further compounded when insurance companies force you to go through a different company to find a psychiatrist versus oncologist or family physician and then deny coverage for treatments and prescriptions.
"These are all forms of individual, systemic, and structural stigmatization built into our culture and institutions," says Dr. Herrick. "Insurers may look at a prescription as a marker for mental illness in general, despite why the medication is being prescribed, and may use that information to deny patients various types of health and life insurance, due to the ostensible 'risk stratification' the medication implies."
In fact, certain health insurance policies and life insurance policies can look at a mental health diagnosis as a disqualifier for coverage, says Dr. Upshaw. That being said, in 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (also known as the mental health parity law or federal parity law) was passed, requiring coverage of services for mental health, behavioral health, and substance-use disorders to be comparable to physical health coverage, according to Gilliland. Despite this legislation, it's still exceptionally difficult to get mental health care covered by many health insurance providers, according to the National Alliance on Mental Illness.
There is a structural challenge for BIPOC, specifically the Black community: Many Black Americans have a deep mistrust of medical professionals, including mental health practitioners, according to psychologist Alfiee Breland-Noble, Ph.D., M.H.Sc., director of the AAKOMA Project, a nonprofit dedicated to mental health care and research.
Historically, Black people have struggled to get adequate, equal care within the predominantly-white medical field, in general. Patients may avoid seeking treatment for any ailment — including mental health care — because they're trying to avoid past situations in which health professionals did not treat them fairly, or were rude, racist, sexist, or homophobic, says Breland-Noble. (Just one example: Harvard shared a 2017 poll in which a third of Black Americans reported experiencing racism at the doctor's office.)
On top of this, it's exceedingly difficult to find a provider they can not only trust but also find commonality with; only 2 percent of psychiatrists and 4 percent of psychologists in the U.S. are Black, according to Breland-Noble. Essentially, Black patients have a 3 percent chance of finding a provider who looks like them, can identify with them, and will understand their world experience — thus further hindering access to quality mental health care that works for them.
The Silent Treatment
The lack of cultural conversation around mental health keeps stigma alive; i.e., the more we don't talk about mental health, the more the stigma grows. As motivational speaker, author, and researcher Brené Brown says when she talks about "speaking shame," sometimes talking about 'the big scary thing' takes the wind out of its terrifying sails. "Shame cannot survive being spoken," says Brown, in one of her most shared quotes. The same goes for this particular stigma — but because mental health is such an intimate, vulnerable thing to discuss, few of people do.
"The stigma persists, from my observations, due to the fact that very few people who use psychiatric medications (or have done so in the past) let others know of their usage," says Talley.
The silence around it not only preserves misconceptions but also prevents patients from getting care. "There has been a greater reluctance for people to seek treatment for mental health problems or talk about them openly when compared to most physical problems," says Gilliland. "If someone is out of work because of cancer treatment, heart attack, or hysterectomy, most people will attempt to make some small talk about how they are doing, how they are recovering, or how they have been. Can you recall a time that someone came back from treatment from depression? How about anxiety? Nope. Not only do we not talk about it but people don't know how to talk to us about it. They don't know what to say or even if it's okay to say something."
The craziest part of all of this? Many of the physical ailments we discuss openly coexist with mental illness. "About 1 in 3 people with cancer or cardiovascular disease experience a depression or anxiety disorder," he says. "It's basically a side effect of the illness or the treatment... but that's almost never discussed." On that note, the same goes for postpartum mental health challenges; it's much easier (typically) for women to talk about 'baby weight' or diastasis recti than it is perinatal mood and anxiety disorders, though they're estimated to affect 10 to 15 percent of new moms.
Guilt By Association
Feelings of personal weakness and guilt contribute to an intrinsic stigma as well. Medications likely have a stigma surrounding them, in part, because of guilt by association: They're associated with mental health problems, which still have a stigma, says Dr. Upshaw.
"There's often a perception that mental illness is somehow a personal weakness that they just need to work on," says clinical psychologist Barbara Wilson, Psy.D.
"If someone does resort to using medication, this is considered similar to someone needing crutches in order to walk — that person is clearly seen as 'not strong' enough to move on their own. Consequently, they need assistance, and that means that they are 'weak,'" explains Forrest Talley, Ph.D., a clinical psychologist in Folsom, CA.
"Within my practice, I haven't seen a bifurcation of 'weak' clients using psychiatric meds and strong clients refusing to do so," says Talley. "The stigma is based on fiction."
Some shame around mental illness and their adjacent prescriptions lingers due to an American state of mind. "Humans have always prided themselves as being in control, to have what we call 'willpower,' what theologians call 'knowing right from wrong,' and what philosophers call 'free will,'" explains Dr. Herrick.
"In America, in particular, our notion of individual freedom, of rights and responsibilities, of fairness and justice, are embedded in our ideas of personhood and citizenship," he says. This can directly impact how we, as a society, feel about medication. "To some, taking a pill for a mental illness calls into question some of our most cherished values of what it means to be human, and also challenges our concepts of individual responsibility when considering the behavior of others."
According to Breland-Noble, the stigma hits Black Americans even harder. This is two-fold. For one, there's the compounded stigma. "If you're a person of color, you're already dealing with so much daily racism and discrimination, microaggressions, macroaggressions, etc. What you don't want to layer on top of that is mental illness, because that stigmatizes and marginalizes you even more," she says. "That, to me, sums it up; you have all these marginalized identities, having an identity of 'being a person who takes meds' for a lot of people is just unbearable."
Second is misinformation or lack of awareness in this community. Some patients, in her experience, believe that you have to "really have something wrong with you" if you're at the level at which medication would be beneficial. "The level of awareness that people of color, in general, have about medications is limited; it's not ignorant, it's a lack of awareness," she says. Growing up, she herself didn't know any BIPOC friends who took psychotropic medication.
The "Label" Problem
It's one thing to feel depressed, but quite another to be prescribed an antidepressant, which takes a feeling ("I feel depressed") to a label ("I am clinically depressed"). And though at times it seems we're genetically programmed to apply labels as a means of survival and identification, they can come with a lot of downsides.
"Our current biomedical model of diagnosing and labeling is, in fact, medicalizing the normal sufferings of life, and can actually increase prejudice and stigma toward those labeled 'mentally ill,'" says Caroline Leaf, Ph.D., a communication pathologist and cognitive neuroscientist. "This happens in four ways: One, it creates a divide between those with a diagnosis and those without one; a 'them and us' mentality. Two, it can end up stereotyping those with a diagnosis as inherently more dangerous or unstable because the problem is located within the biology of the individual. Three, it positions those with a diagnosis as part of an 'out-group.' And four, it can lead to discrimination and socioeconomic disadvantage for those diagnosed with certain 'diseases.'"
No one wants to be labeled, especially when that label can harm so many aspects of your everyday life. And with medication, it's easier for doctors, pharmacists, insurance companies, employers, and peers to apply a label. "Labels can lock people into negative, toxic cycles, whereas validation, compassion, and self-awareness can bring lasting healing," says Leaf. "People need to be listened to and supported through their issues."
There's a positive case to be made for labels: They can give people an anchor point of sorts, help validate their experience, and in turn help them find community with others who share a similar lived experience. (Take the queer community, for example.) That said, labels don't come without all the drawbacks above, as well.
Medication Doesn't Tell the Whole Story
On that note, it's incredibly important to remember that medication doesn't define you, and there's nothing "wrong" with you. "It's completely normal to feel anguish, despair, anxiety, and depression in response to the challenges and tragedies of life — we need to stop stigmatizing normal human emotions and reactions," says Leaf. "More and more of us are struggling with anxiety, intrusive thoughts, depression, and fear, which is causing problems with concentration, burnout, strained relationships, physical health problems — you name it!"
"Unfortunately, management of mental health has become ever more biomedical and neuro-reductionistic over the past fifty years," she says. Neuro-reductionistic means we've focused on the physical aspect of the brain, rather than focusing on your story, what you've experienced, and the political and socioeconomic environment you live in, she explains. Those are often overlooked in favor of the "philosophy of 'my brain made me do it,' which tends to increase stigma since the problem is in your biology, not the world you live in or the way society has failed you."
There are valid medical concerns when it comes to psychiatric medication, particularly when it comes to addiction and side effects (which — surprise! — fuel the stigma).
Fear of Addiction and Medical Double Standards
"To an American, the word 'dependency' is as close to a slur as any slur that can be imagined, because it goes against our grain as fiercely independent people," says Dr. Herrick. "And in medicine, the word has been used from time immemorial to connote addiction, an inability to exert will power and spiraling into a self-destructive path of drug or alcohol abuse."
But is needing medication — for anything — truly dependency? This notion is quite pejorative and ignores the fact that we all depend on something — particularly our friends, family, and community — to survive, says Dr. Herrick. "And in medicine, it belies the fact that most of today's serious medical conditions, such as heart disease, diabetes, and even cancer, are chronic conditions requiring us to take medications on a daily basis in order to function and stay healthy."
To boot, not all medications are addicting (this isn't to say that they're all universally benign and perfect, mind you). "I'm still surprised that so many of my patients have misinformation on antidepressants such as they'll become dependent on them, or they'll be addicting, or they will change their personality," says Dr. Wilson. "Many tend to suffer the effects of anxiety or depression and 'push through' on their own rather than be willing to try the medications."
Fear of Side Effects
"Unwanted side effects are a real concern," says Dr. Upshaw, "Including sexual side effects and weight gain — and they can have discontinuation side effects when you try to stop them."
Leaf agrees. "We need to be careful, as these drugs can have very negative side-effects, especially if taken for long periods of time," she says. "Psychotropic drugs can directly affect your health with [sometimes severe] side effects." She emphasized that this type of treatment (medication) is "not a 'magic pill' or cure-all."
That said, there are side effects to any kind of substance you consume (whether that's coffee, bread, a multivitamin, a margarita, or an antidepressant). It's important to know the potential side effects of everything, but some doctors argue that the side effects of psychiatric drugs are a bit misunderstood. "Many patients believe the misinformation that antidepressants can cause someone to commit suicide, which is extremely rare, and has other contributing factors besides the effects of the medication," says Dr. Wilson.
Misinformation About "Natural" Approaches
There are tons of non-pharmacological interventions for mental health (seriously, so many) that don't involve a single prescription. Whether that's cognitive behavioral therapy, yoga, breathwork, or all of the above, there are more options than ever before to work through mental challenges and illness.
"Learning how to manage the mind lays the foundation for true and lasting change, and helps promote and sustain healthy, lifelong habits," says Leaf, citing her 30 years of clinical research on learning and neurophysiological functioning.
And that's not even getting into the naturopathic approach, which involves certain supplements. "There is data that shows that certain natural remedies are helpful in mental health (i.e. melatonin for sleep disorders, omega-3 fatty acids for depression)," says Dr. Rivera. But, of course, "there's also much data showing how prescription medications are helpful in the treatment for mental illness."
It's true that, in most cases, doctors will opt for the mildest treatment first. "Most of our health care starts with the least invasive procedure and moves up the chain to more invasive procedures unless there's a crisis that necessitates more invasive right from the start," says Gilliland. This applies to mental health as well (and a prescription could be considered more 'invasive').
"With that being said, we should look for counseling, exercise, meditation, work, spirituality, and plant-based supplements and nutrition to all have positive effects on our mental and physical health," says Gilliland. "In the early stages of hypertension, the recommendation is 'eat right and exercise,' and that is good medicine. Likewise, there are some patients who gain benefits from counseling alone, exercise alone, nutrition and supplements alone. If your symptoms decrease and you're doing more of the things in life you enjoy, that's great. If not, then we need to look at adding things so that you can have a life worth living."
What Does "Natural" Mean?
The problematic part of all this is when 'natural' is seen as the only good option (and not just good, but morally 'superior') and Western medical treatments are seen as 'bad' or 'evil' — especially because it's hard to define what 'natural' really means.
Remember: Even plants are made of chemicals. "The notion that plants are safer than pills is the driving force behind the push to choose 'natural treatments,'" says Dr. Herrick, but "all chemicals, whether natural or man-made, are neither good nor bad, with both having the potential to cause harm or cure."
"'Natural' has become a kind of panacea in our world today, especially in response to the current failings of our mental healthcare system," says Leaf. "While I understand the draw of a more natural approach to mental health, I am also wary of the promises made by the wellness industry, as well as the shame and guilt that comes along with failed promises — people can think there is something wrong with them if the yoga or meditation or breathwork or supplements are not working, which can exacerbate someone's mental distress."
We're dealing with double standards in this arena. Talley shared another example of the faulty stigmatic logic that shrouds psychiatric medications, particularly when it comes to what kinds of substances — natural versus 'chemical' — people consume. "What about the widespread use of caffeine?" says Talley. "How often do we all hear someone say 'I need my morning coffee to get up and running for the day?' Caffeine is not naturally produced by the body, but it's more commonly used as a mental stimulant than any pharmaceutical prescribed by psychiatrists."
"There's good science backing some natural remedies, though you have to be careful because many of them have not been rigorously studied and do not carry the backing of the FDA," says Dr. Upshaw. And you also need to recognize where medication might be the right choice.
You Don't Have to Choose Between Natural and Pharmaceutical
Pitting plants and pills against one another can do patients a disservice, because "one does not exclude the other," says Dr. Rivera. Overall, the idea that natural remedies should replace scientifically proven medications can be problematic, says Dr. Upshaw. Natural remedies can be valid, but messaging that they're valid because medical remedies are harmful is a problem. "Most of the patients I see understand that if their symptoms are severe enough, they should consider medication treatment" rather than over-the-counter natural remedies, he says. "There is still a role for medications, and they remain an important treatment option for people struggling with mental health problems."
"When symptoms are mild, there can be a role for natural remedies," agrees Rivera. "When symptoms are affecting someone's functioning (personal, professional and socially) it is time to consider the role of therapy and/or medications. For those who are unsure of using medication, engaging in regular therapy can help alleviate some of the symptoms and improve functioning. Always knowing that medications may be needed and that these can be life-changing and at times even life-saving."
Sometimes Both Is Better
Talley shared an analogy that might resonate:
Of course, every person's car-in-a-ditch situation will be different — and so will the solution. "When approaching any illness, you have to take each person as an individual rather than a one-size, fits-all approach," says Dr. Herrick. "It's important to keep an open mind, be flexible with your treatment plan to give yourself the greatest possibility of success, work closely with your provider and together, choose the right pathway for your particular diagnosis."
How to Overcome the Stigma
So, you're probably thinking, "cool, but what can we actually do about all this?" Though the stigmas are deeply rooted, centuries-old, and incredibly complex, there's a pretty easy way to start breaking them down: talking about mental health.
Talk About It
If you're in a position to talk about your own mental health struggles, know that you can make a difference just by speaking up. "I think the most powerful thing we've seen is people in visible positions — athletes, actors, musicians, politicians, authors, CEOs — who have talked about their mental health like they talk about their physical health," says Gilliland. "It's an aspect of who they are but not the defining characteristic. We've also seen a shift in how mental health is portrayed in movies in a way that is more accurate and hopeful, which was not the case in years past."
"More importantly, educating the public on how mental illness is more a matter of an individual struggling to adapt to a toxic environment rather than either suffering from a 'brain disease' (which can inadvertently increase stigma) or 'mental illness' with its negative connotations of 'weakness of the will,' is imperative," says Dr. Herrick. Reinforcing the idea that these conditions are a product of the individual in their environment helps to relieve the stigma and allow for more flexible solutions.
Vocabulary Is Important
When you do speak about mental illness, it's important that you're careful with your words. "Mental health terms and diagnoses have also been popularized in a way that minimizes how significant the disease can be," says Rivera. "They unfairly become common adjectives to describe normal day-to-day behaviors and not necessarily clinical symptoms. For example; calling someone 'bipolar' when they are simply irritated." (Related: Why You Should Stop Saying You Have Anxiety If You Really Don't)
Consider this advice when using everyday words such as 'crazy,' or 'psychotic' — this may seem like a severe approach, but consider how much the collective vocabulary has changed in the past 10 or so years; perhaps there were words that once felt commonplace that have been completely eradicated from your vocabulary in order to protect stigmatized, marginalized groups. Our language is evolving as our culture becomes more educated, open, and supportive of one another.
Educate Yourself and Others
The more truths we know, the less chance stigma has at survival.
"I learned first hand just how dangerous misinformation is and can be," says Stevanovich, reflecting on her experience with mental health stigma (particularly around her medications). "I learned that I need to fight even harder with my organization Braintuff to educate, educate, educate. There is so much bad information out there, and if I can help someone else do what I did — cut the noise, ditch the misinformation, and listen to my body and doctor — then I've done my job." (Related: 8 Things You Absolutely Need to Know If Your Partner Has Anxiety, According to a Therapist)
"Every brain is different, and for one person a medicine might not work out at all, while that same medication is a lifesaver for another," she says. "The more we educate the public on mental health, the healthier we'll all be."
Take Care of Yourself
Focus on feeling good and thriving, and allow others to follow your example. Put effort into taking the best care of yourself, and if you're feeling up to it, talk about your struggles, too. The more we humanize this experience and show that this is just one part of a happy, fulfilling life, the more we can destroy the stigma hovering over all things mental health. Plus, you feeling good means one more healthy and happy person in the world — and this isn't just about taking medication!