Elsevier

Social Science & Medicine

Volume 146, December 2015, Pages 53-61
Social Science & Medicine

My dirty little habit”: Patient constructions of antidepressant use and the ‘crisis’ of legitimacy

https://doi.org/10.1016/j.socscimed.2015.10.012Get rights and content

Highlights

  • Participant accounts pointed to depression and antidepressant legitimacy concerns.

  • Moral uncertainty and distress means patients struggle to decode legitimacy/illegitimacy.

  • Antidepressant counter-stories (e.g. increased authenticity) challenge illegitimacy.

  • The legitimacy quandary powerfully shapes antidepressant interpretations and use.

  • Patients might more pragmatically manage antidepressants via our study findings.

Abstract

Discontents surrounding depression are many, and include concerns about a creeping appropriation of everyday kinds of misery; divergent opinions on the diagnostic category(ies); and debates about causes and appropriate treatments. The somewhat mixed fortunes of antidepressants – including concerns about their efficacy, overuse and impacts on personhood – have contributed to a moral ambivalence around antidepressant use for people with mental health issues. Given this, we set out to critically examine how antidepressant users engage in the moral underpinnings of their use, especially how they ascribe legitimacy (or otherwise) to this usage. Using a modified constant comparative approach, we analyzed 107 narrative interviews (32 in UKa, 36 in UKb, 39 in Australia) collected in three research studies of experiences of depression in the UK (2003–4 UKa, and 2012 UKb) and in Australia (2010–11). We contend that with the precariousness of the legitimacy of the pharmaceutical treatment of depression, participants embark on their own legitimization work, often alone and while distressed. We posit that here, individuals with depression may be particularly susceptible to moral uncertainty about their illness and pharmaceutical interventions, including concerns about shameful antidepressant use and deviance (e.g. conceiving medication as pseudo-illicit). We conclude that while people's experiences of antidepressants (including successful treatments) involve challenges to illegitimacy narratives, it is difficult for participants to escape the influence of underlying moral concerns, and the legitimacy quandary powerfully shapes antidepressant use.

Introduction

Oddly enough there's a dark kind of [er] distrust of it [antidepressants]… the science is not right.

[Tony, UKb]

In this paper, we start from the position that common pharmaceutical treatments – broadly “antidepressants” – while useful for many patients personally (and health-care professionals in their work) can be experienced in problematic ways in everyday practice. Like many other aspects of social life, we posit that antidepressant use is morally laden and susceptible to claims of illegitimacy (as are their users). In seeking to manage this issue, people deploy a moral framework in an attempt to evaluate or judge the rights and wrongs of the medications and the ways in which they are used. This may variously include evaluating (and feeling judged by) others, attempting to defy or conform to apparent social norms, managing feelings of shame, attempts to lead the “good life” so as to feel virtue, and so on (Sayer, 2005). Our study draws on the experiences of antidepressant users to unpack key moral underpinnings of everyday practice, illustrating how the ambiguous positioning of antidepressants – and subsequent interpretations of them – influence the experiences of people with depression in significant and at times problematic ways.

To highlight the seriousness of depression as a major contributor to the global burden of disease, the World Health Organization (2012) proclaimed that depression had become the leading cause of disability worldwide. However, in considering antidepressant legitimacy, it is important to acknowledge that behind this announcement, the 20th Century development of depression as an illness category was contested (McPherson and Armstrong, 2006). Depression has ongoing ideological, historical and professional ‘baggage’ that shapes the use of various therapeutic offerings, including antidepressants. That is, the legitimacy of the illness flows through to the legitimacy of the therapeutic interventions (although not in any clear linear way). For instance, disagreements remain regarding depression subtypes, cause(s), symptomatology, and the benefits of antidepressants vis-à-vis other therapeutic practices (e.g. psychotherapy) (Pilgrim, 2007, Kirsch et al., 2008). The codification and treatment of depression was influenced by the biological hegemony gained over those advocating psychoanalysis in 20th Century US psychiatry (McPherson and Armstrong, 2006). The politics are ongoing, and in recent years, there has been controversy about depression and its treatments, captured in the reception of the latest Diagnostic and Statistical Manual of Mental Disorders DSM (V) – the widely influential American Psychiatric Association (APA) manual. In particular, the DSM (V) was criticized for re-classifying normal grieving as potentially part of major depression (Wakefield and First, 2012). This move by the APA was cited as an instance of the wider problem of expanding the diagnosis of depression to medicalize difficult emotional states (Dowrick and Frances, 2013, Kokanovic et al., 2013).

To understand why modern-day antidepressant use is so publically contested requires some historical perspective. Prozac – one of the first and most famous of a new class of antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs), introduced in the 1980s – was initially touted as a wonder medicine, and subsequently immortalized in the public imaginary by books like Prozac Nation (Wurtzel, 2002). However, following the typical lifecycle of all new medications, concerns soon emerged about the medicine (Metzl, 2001). Stories of failure and violence soon emerged in the media (Moore, 2007), although subsequent research failed to find evidence of this link (Walsh and Dinan, 2001). In this climate – along with concerns over the legitimacy of depression – patients could easily become confused and disillusioned about using antidepressants for apparently personal and social ailments (Karp, 1993, Britten et al., 2010). In addition, recovery from depression is likely without pharmaceutical treatment, further bringing into question the value of medication (Ridge and Ziebland, 2006).

From about the mid-2000s, the general reputation of antidepressants began to suffer further when a bias in reporting positive results from randomized controlled trial evidence of SSRIs in medical journals was identified (Editorial, 2004). Subsequently, there were concerns about the lack of effectiveness of SSRI treatments for all but the most serious forms of depression (Kirsch et al., 2002, Kirsch et al., 2008). Some researchers openly began to discuss antidepressants as ineffective (Buus, 2014). Additionally, the widely held theory that antidepressants work by correcting abnormal serotonin/noradrenaline levels in the brain was questioned (Middleton and Moncrieff, 2011). Research showed that other therapeutic options (like counseling and even acupuncture) might be of more use to patients (MacPherson et al., 2013). Nevertheless, many of those on the frontline of depression treatment remained upbeat: patients frequently self-report that antidepressants work well, including over the long-term (Ridge, 2009), while general practitioners commonly report their effectiveness (Hyde et al., 2005).

The potential for antidepressant over-use is part of the contestation of the medications. In Australia and England, the prescription of antidepressants increased by 95% over 11 years and 165% over 14 years respectively (Stephenson et al., 2013, Spence et al., 2014). These prescription increases cannot be adequately accounted for by increased prevalence, nor improved depression diagnoses. While population increases – and longer treatment periods – may partly explain these upsurges, research also implicates changing doctor prescribing habits (Mercier et al., 2011, Ilyas and Moncrieff, 2012). Social issues are also driving increased antidepressant use, e.g. low socioeconomic status and declining house prices (as a proxy for financial distress) (Lin et al., 2013, Wemakor et al., 2014), and a preference for cheap mental illness treatments (Gussin and Raskin, 2000).

Critical social researchers have addressed the complex ways in which medications – particularly psychoactive ones – are used, interpreted and become part of the public “imaginary” (Schlosser and Hoffer, 2012). Patients are frequently reluctant to take psychoactive medication for various reasons (e.g. fears of addiction), and may reduce or stop their medication unilaterally (Pound et al., 2005). Research has also indicated that patient self-regulation leads to conflicts with health professionals, previously captured under the lop-sided rubrics of “compliance” and “adherence” – concepts which favored professional perspectives (Osterberg and Blaschke, 2005; O'Connor, 2006). Today, social research focuses on how medication-taking is negotiated and becomes meaningful to patients (Shoemaker and Ramalho de Oliveira, 2008). Key issues like the quality of relationship with doctors and patient sense of control influence the interpretation and use of medications (Benson and Britten, 2002). Here, patients are increasingly considered to be active agents in medication management. In the area of antidepressants, patient resistance is long documented (Karp, 1993), and initial willingness to take antidepressants can give way to uncertainty around managing depression pharmaceutically (Buus, 2014). Patients may subsequently experiment by modifying their medication use without professional input.

Moral issues abound in climates of imperfect understanding and treatment. For instance, a meta-ethnography of 16 qualitative antidepressant studies (Malpass et al., 2009) uncovered the notion of a “moral career” for patients of antidepressants, which was later elaborated on by Buus (2014). The moral career concept highlighted the range of complex tasks patients work through like questions around stigmatization, concerns about psychological dependency, and sense of duty to become well (and forms of moral virtue therein). However, this moral career concept was not explicated in detail and is worthy of elaboration (Buus, 2014). SSRIs are also discussed in the “moral enhancement literature”, as a way of managing aggressive impulses (Wiseman, 2014), thus bringing debates full circle from the initial reports linking Prozac and violence. Less discussed around antidepressants until now is their relationship with illicit drugs. Cohen et al. (2001), for example, note that whereas cocaine and Ritalin (for attention deficit hyperactivity disorder - ADHD) share strikingly similar stimulant qualities, the first is illegal and the second given to minors with reported social benefits (Singh et al., 2010). Despite studies elucidating distinctly moral dilemmas associated with antidepressants, little or no narrative research has specifically set out to investigate and outline a moral framework of antidepressant use, based around the quandary of legitimacy as highlighted above.

Section snippets

Methods

This paper uses a qualitative secondary analysis to examine a research question not examined in the original studies: “How do participants understand their antidepressant use morally, and how do they formulate legitimacy therein?” We use the term secondary analysis in the sense that although the original researchers of all studies were involved in the current study, we investigated a research topic that was new and distinctive (Heaton, 2004). To investigate our research question, we combined

Aims

The overall aim of the study was to examine in detail the moral framework of a broad sample of antidepressant users, specifically centered on concerns about the legitimacy of use. The combined narrative data from three UK and Australian narrative data collections provided a particularly rich source of qualitative data for secondary analysis. This paper expands on the original work by focusing on narrative accounts relating to views, feelings, interpretations and experiences of antidepressants.

Results

My general experience of antidepressants has been very positive in terms of all the horrible things that people talk about that can happen with them.

[Tony, UKb]

Firstly, in this section we outline our findings in terms of antidepressant legitimacy issues (e.g. including wider social discourses on the medications, shame and stigma). We then discuss how participants attempt to cope with legitimacy concerns about their own usage. We subsequently cover pseudo-illicit interpretations of

Discussion

Our paper began by outlining some discontents surrounding the category of depression as a diagnostic term, and the associated mixed fortunes of antidepressants. While many doctors and patients are adamant that antidepressants are a useful treatment when used appropriately (Ridge, 2009, Hyde et al., 2005), doctors frequently have insufficient time to adequately explain their use and value, and questions around their effectiveness, morality and legitimacy continue. Our study examined this moral

Conclusion

Despite the differences in time and distance between the datasets, we found remarkably consistent moral ideas around antidepressants among participants. This is perhaps not surprising given the historical lineage between Australian and UK culture, as well as the globalization of depression and its treatments (Bhugra and Mastrogianni, 2004). Similarities in the samples also suggest that desires to avoid stigma, like the malingerer label, are commonly experienced by users. With the failures of

Acknowledgments

We would like to sincerely thank our participants who shared with us their intimate stories so generously. In particular, we would like to thank the anonymous reviewers and Elizabeth Murphy for reading the paper critically, Sam Cadman and Nicholas Hill for editing and preparing the manuscript for submission. The Australian study was funded by the Australian Research Council (ARC) Linkage project scheme [LP0990229]. UKa was funded by the Health Department. UKb was funded by the National

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