Imagine walking to the pharmacy counter with your psychiatric prescription tightly folded in your hand. The shop is busy and you are waiting for everyone else to leave so that you can speak up. When pharmacist asks you what you need, your voice drops to a near whisper, because you don’t want anyone else to hear the name of your medicine.
For many people living with mental health condition everyday life may feel manageable, but a visit to a medical store can feel very different. The judgmental looks of strangers can reopen old wounds. It is not only about collecting medicines, it is about exposing a vulnerability, and wondering who might be judging you, who might be watching you, who might be talking about you afterwards. Some people get through it; others start skipping the visit altogether.
What does the research tell us?
Mental illnesses are among the most widely stigmatized disorders globally, despite the evidence that they result from imbalance of neurochemicals in the brain rather than moral failings or witchcraft, as often perceived by public. Stigma creates barrier to recovery and positive treatment outcomes.
A 2022 systematic review of 40 studies across six continents found that stigma can make taking psychiatric medicines feel risky. Many people felt that taking these medicines marked them as “psychiatric patient” and some even hid their medicines for fear that colleagues or partners would find out. Visible side effects such as weight gain and tremors made the embarrassment even deeper.
Perceived stigma plays an important role in eroding patient’s self-esteem causing social withdrawal and prevents individuals from seeking mental health treatment. Taking medicine as prescribed is hard in every long-term illness, but it is especially hard when a person is suffering from some mental health illness. A 2013 review found that between 30% and 50% of medicines for long-term condition are not taken as they should be, with psychiatric conditions running at similar rates. The distinction in mental health care is the added burden of stigma on top of the usual impediments. There are a number of reasons for non-adherence but stigma is one we can change.
How stigma hinders treatment adherence?
Stigma doesn’t stop a person from taking medication through physical force; rather, it operates through complex interplay of psychological and social mechanisms that erode the will to continue treatment. Researchers describe three pathways to this;
1. Social stigma: Negative stereotypes in society lead to judgement and discrimination. A person suffering from a mental health disorder, often hide their medicines from people, or diagnosis from people, or stop their treatment altogether to avoid being found out.
2. Self-stigma: When the social stigma is internalized by the person deeply. Overtime, this can result in low self-esteem, shame, and hopelessness. The person doesn’t even try to seek help even when it is needed the most. This is what self-stigma does!
3. Anticipated stigma: It is the fear that one will be stigmatized if their illness becomes known. This leads to label avoidance, that is, turning down the psychiatric treatment altogether, because accepting treatment feels like accepting a label.
Side effects may compound all three of above issues. Yet some do not have such reservations; surrounded by supportive people, they view their medicine as just another element of self-care.
What happens when treatment stops?
The medicine that was meant to protect person’s stability, if skipped carries a deep cost. It is a painful irony that someone who has concealed their treatment to sidestep judgement can become more exposed than they were to begin with. Non adherence is tied to relapse and hospitalisation. Should one be considering discontinuing a medicine, the psychiatrist should be consulted first so as to determine how to do so safely.
What can help?
• Psychoeducation. Clear, kind education can help rectify myths and provide patients with scientific explanations for their condition, reducing the power of social stereotypes.
• Cognitive behavioral therapy-based strategies are helpful in helping the patients identify and modify internalized stigma.
• Narrative Enhancement Cognitive Therapy (NECT), a structured way of dealing with self-stigma through a mix of psychoeducation, storytelling and cognitive restructuring. Studies have looked into how it might aid recovery and self-esteem in those with serious mental illness.
• Peer and family support helps the patient realize that they are not alone, directly combating the isolation caused by stigma.
• Public awareness campaigns are necessary to improve the community mental health literacy and reduce the stigma.
A closing thought
Walking up to the pharmacy counter with your psychiatric prescription is not just acknowledging the illness but also an act of courage and self-care. It deserves respect, never whispers or stigma. Medicine for mind is simply a medicine. Just like we take medicine for other physical illnesses to feel better, we expect the same from these medicines as well. Let’s make pharmacy a place where nobody feels ashamed of taking care of themselves.
References:
Chapman, S. C. E., & Horne, R. (2013). Medication nonadherence and psychiatry. Current Opinion in Psychiatry, 26(5), 446–452. https://doi.org/10.1097/YCO.0b013e3283642da4
Chukwuma, O. V., Ezeani, E. I., Fatoye, E. O., Benjamin, J., Okobi, O. E., Nwume, C. G., & Egberuare, E. N. (2024). A systematic review of the effect of stigmatization on psychiatric illness outcomes. Cureus, 16(6), Article e62642. https://doi.org/10.7759/cureus.62642
Crowe A, Averett P, Glass JS, et al.: Mental health stigma: personal and cultural impacts on attitudes. J Couns Psychol. 20161, 7:97-119. 10.22229/SPC801925
Dubreucq, J., Faraldo, M., Abbes, M. et al. Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial. Trials 22, 124 (2021). https://doi.org/10.1186/s13063-021-05067-1
Febrinasari, N., Widayanti, A. W., Prabandari, Y. S., & Satibi, S. (2024). Perception, attitude and stigma of community pharmacists toward patients with mental disorders: A cross-sectional study. Journal of Public Health and Development, 22(1), 209–223. https://doi.org/10.55131/jphd/2024/220116
Henssler, J., Schmidt, Y., Schmidt, U., Schwarzer, G., Bschor, T., & Baethge, C. (2024). Incidence of antidepressant discontinuation symptoms: A systematic review and meta-analysis. The Lancet Psychiatry, 11(7), 526–535. https://doi.org/10.1016/S2215-0366(24)00133-0
Sewilam AM, Watson AM, Kassem AM, et al.: Suggested avenues to reduce the stigma of mental illness in the Middle East. Int J Soc Psychiatry. 2015, 61:111-20. 10.1177/0020764014537234
Sewilam, A. M., Watson, A. M. M., Kassem, A. M., Clifton, S., McDonald, M. C., Lipski, R., Deshpande, S., Mansour, H., & Nimgaonkar, V. L. (2015). Suggested avenues to reduce the stigma of mental illness in the Middle East. International Journal of Social Psychiatry, 61(2), 111–120. https://doi.org/10.1177/0020764014537234
Townsend, M., Pareja, K., Buchanan-Hughes, A., Worthington, E., Pritchett, D., Brubaker, M., Houle, C., Mose, T. N., & Waters, H. (2022). Antipsychotic-related stigma and the impact on treatment choices: A systematic review and framework synthesis. Patient Preference and Adherence, 16, 373–401. https://doi.org/10.2147/PPA.S343211