Perceptions of and Attitudes Toward Antidepressants Stigma Attached to Their UseVA Review Joa ˜ o Maurı ´cio Castaldelli-Maia, MD,*Þ Luciana Burim Scomparini, MD,*Þ Arthur Guerra de Andrade, MD, PhD,*Þ Dinesh Bhugra, MA, MSc, MBBS, FRCP, FRCPsych, MPhil, PhD,þ Tania Corre ˆa de Toledo Ferraz Alves, MD, PhD,*Þ and Gilberto D’Elia, MD, PhD* Abstract: The aim of this study was to ascertain whether there is any evi- dence of stigma related to the use of antidepressants. Using the PubMed and MEDLINE databases, we searched for the terms stigma, antidepressants, and depression. A protocol was developed to extract information from the papers, which were identified and explored further. Thirty-two papers were identified. We found that the stigma against depression differs from stigma against the use of antidepressants. Stigma against depression does not impact on therapeutic adherence to antidepressant use. Stigma related to antidepressant use appears to be linked with perceived emotional weakness, severity of illness, an inability to deal with problems, and a lack of belief in the therapeutic efficacy of anti- depressants. Stigma against medication can be a useful target for interventions, just like the stigma related to depression. However, clinicians must be careful in avoiding the medicalization of symptoms. Key Words: Stigma, depression, antidepressants, use, interventions. (J Nerv Ment Dis 2011;199: 866Y871) S tigma is a social construct that defines a person based on a specific or distinctive characteristic or mark that has as its pri- mary consequence the devaluation of the individual. The prejudice against individuals has dated for centuries and is linked with the creation of the other so that individuals making such assertions can validate their own identity. The stigma against mental illness is in- fluenced by a number of factors such as the nature and gravity of the disease, as well as the personal relationship to the disease and the degree of willingness to reveal its existence to others (Dinos et al., 2004). This stigmatization can lead to a prejudiced treatment of patients who may have either physical or emotional diseases, de- pending on individual and sociocultural characteristics (Dickstein, 2002). Therefore, stigma against psychiatric patients marks the indi- vidual as the possessor of undesirable characteristics and therefore deserving of censure by others (Dickerson et al., 2002). Consequently, patients with mental health problems report feelings of despondency, hurt, anger, and low self-esteem (Wahl, 1999). Despite the recent World Psychiatric Association campaign that led to various initia- tives around the world, evidence shows that national interventions do little to change the prejudicial treatment and negative attitudes ex- perienced by the patient (Molodynski, 2006). Stigma may also be partly responsible for the difficulty and delay in technical and scientific progress in the psychiatric area as a result of limited or poor research funding, which leads to poor funding and support (Barchas et al., 1985). Stigma is both a persistent and a difficult problem to combat to affect progress in the mental health area (Magruder and Yeager, 2007), although there have been more opti- mistic findings recently (Sudak et al., 2008). The families of patients with mental illnesses tend to hide the fact from others (Angermeyer et al., 2003; Ohaeri and Fido, 2001; Phillips et al., 2002; Shibre et al., 2001). Whether stigma is related to terms used and whether by changing these, stigma will be reduced remain open to speculation (Kingdon et al., 2008; Turner, 1986). Different psychiatric disorders carry different types and levels of stigma (Kanter et al., 2008). Spe- cific disorders such as alcohol and psychoactive substances (Ronzani et al., 2009), general anxiety disorder (Culpepper, 2002), eating dis- orders (Andersen and Holman, 1997), and bipolar disorder (Cole, 1999) also carry stigmatizing attitudes to them. Great strides have been made in treating depression particularly in the neurobiological field (Rot et al., 2009). Despite an increase in the optimism and resolution of various psychiatric disorders, pro- longed pharmacological treatment remains notoriously difficult for various reasons (Chakraborty et al., 2009; McMullen and Herman, 2009). The intensity of their symptoms, types of symptoms, and their resolution as well as explanatory models may contribute to ther- apeutic adherence. For example, it has been argued that depression can be recognized as a disease of those unable to deal with problems (Interian et al., 2007; Malpass et al., 2009). An important metaeth- nography (a method used to synthesize qualitative research findings) has suggested that depression as an illness may be seen as dishon- orable by the patients using the medication (Malpass et al., 2009). Depression can also be associated with the idea of emotional weakness (Comas and Alvarez, 2004; Interian et al., 2007) and thus may be seen as inappropriate for reporting to the clinicians more difficult (Montano, 1994). It is inevitable that stigma will affect the diagnosis of depres- sion (Hirschfeld et al., 1997). The patients may choose not to express emotions but may also not be able to express emotions as a result of discomfort stemming from the stigma (Hirschfeld, 1998). Patients may minimize their depressive symptoms, becoming reluctant to seek out professional help because of the stigma associated with mental illness in general, and may try to attribute their symptoms to inter- nal organ problems (Goldman et al., 1999). On the other hand, some clinicians may find it difficult to ask about symptoms of depres- sion as reported by primary care professionals (Thobaben, 1998). An English metasynthesis (an attempt to integrate the results from a number of different but interrelated qualitative studies) points out the difficulty the patient has in telling others that he or she is de- pressed (Khan et al., 2007). Few intervention studies have been re- ported (Paykel et al., 1998). The stigma of depression was regarded as one of three classes of barrier to the treatment (Simon et al., 2004) and could be an im- portant intervention target to ensure better treatment adherence and REVIEW ARTICLE 866 www.jonmd.com The Journal of Nervous and Mental Disease & Volume 199, Number 11, November 2011 *Department of Psychiatry, Medical School, Funda0a ˜o do ABC, Santo Andre ´, Brazil; †Department of Psychiatry, Medical School, Universidade de Sa ˜o Paulo, Sa ˜o Paulo, Brazil; and ‡Institute of Psychiatry, King’s College, London, United Kingdom. Send reprint requests to Joa ˜o Maurı ´cio Castaldelli-Maia, MD, Departamento de Psiquiatria, Faculdade de Medicina, Funda0a ˜o do ABC, Avenida Lauro Gomes, 2000, Vila Sacadura Cabral, Santo Andre ´, SP, Brasil, CEP 09060-650. E-mail: jmcmaia2@gmail.com. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0022-3018/11/19911<0866 DOI: 10.1097/NMD.0b013e3182388950 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.