displays the characteristics of the sample. Although there was some diversity across the demographic variables, the participants were mostly women from Puerto Rico, the Dominican Republic, and Mexico. Issues of stigma frequently occurred in participants' descriptions of their experiences with antidepressants. Of the adherence complications, stigma ranked second only to side effects, which was discussed by 26 (87%) of the participants. Twenty-two (73%) participants made comments that were coded as being related to stigma. There were 86 instances of stigma coded by the raters overall.
Characteristics of 30 Latino outpatients receiving antidepressants
An expected finding was participants' perception that experiences with depressive symptoms are labeled negatively, particularly within their social contexts. This labeling extended to both their depression and use of antidepressant medication. One participant described the label for antidepressant use, “Yo si oía decir de la medicina de que eso era para locos.” (I did hear people say about the medicine that it was for crazy people.)
Ample evidence emerged that illustrated the negative attributes that participants associated with antidepressant medication. Participants appeared to struggle with many of these negative attributes mostly when first confronting their diagnosis and with the commencement of antidepressant treatment. The examples we present are mostly participants' own expressed thoughts during this process and not necessarily comments from others.
One negative association of antidepressants was that they were for “severe” cases. One participant reported her initial reaction to the treatment recommendation, “¿Bueno, tan grande es mi problema?” (Well, so my problem is that big?) Weakness and inability to deal with life's problems were also reported to be among the negative associations linked to depression and antidepressant medications. This view was illustrated by some of the pejorative labels reported—for example, floja or weak, inútil or useless, and chiquitita or small. Reactions to the initial recommendation for antidepressant medications again illustrated the role that these negative associations played.
“Ay Dios mío, que inútil yo voy a ser…. Me sentí muy chiquitita. Por que si yo estoy bien, yo no necesito eso. Yo estoy bien. Yo podía hacer mis cosas sin medicamento. Yo podía. Yo era otra persona. ¿Por que me pasa esto? ¡Ay, mucho!” (Oh my God, how useless I will be…. I felt very small. Because if I'm fine, I wouldn't need this. I'm fine. I could do my things without medication. I could. I was another person. Why does this happen to me? Ahh, too much!)
Taking antidepressants was also seen as subjecting one to some of the negative associations typically related to taking drugs. This included the potential for addiction, which has long been a common misperception with antidepressants. It should be noted that drug addiction has an independent and very negative connotation in Latino culture. Negative perceptions also included the fear that others would associate taking antidepressant medications with being under narcotic effects.
“Muchas de las personas piensan por el hecho de estar tomando medicamentos antidepresivos es como las personas que toman cocaína y todas esas cosas, que van a estar así.” (Many people think that because they are taking antidepressant medications, it's like people who are using cocaine and all those other things, that they're going to be like that.)
Participants depicted a social environment that carried negative connotation and disapproval related to depression and antidepressant medication. Whether by fear of negative evaluation or actual behaviors from others, one result from such a social context was the experience of separation for those who were targets of stigma. For example, separation was evident in the use of labels for antidepressants—for example, “para los locos” (for crazy people). Also, separation occurred when the cultural context was such that the use of antidepressant medication was not normative. Cultural expectations described by participants emphasized being resilient and coping with life's problems without antidepressants. Taking antidepressants seemed to subject participants to disapproval from their family and social support systems. One family member reportedly stated, “Yo tantos problemas que he tenido y nunca he tenido que ir a un psiquiatra. ¿En que fallaste tu? ¿Qué tu hiciste?” (I've had so many problems, and I have never had to go to a psychiatrist. What did you fail in? What did you do?)
In these instances, family members were described as exerting a direct influence on whether the medications should be taken. Such stigma would also contribute to family dysfunction in the form of conflicts, negative statements, and limited support. These consequences are noteworthy given that those with depression are already likely to be struggling with a negative sense of self and interpersonal dysfunction. It should be noted that such lack of support was not reported by all participants.
Other consequences were described in occupational and social domains. A notable example was related to discontinuation of antidepressant medication before seeking employment. The participant described concern about being negatively evaluated as a result of antidepressant treatment. Other examples described a fear of the social impact of being seen entering the mental health clinic.
Although discussing issues related to depression and antidepressants, participants revealed instances of both acceptance of and resistance to stigma. Some participants revealed clear examples of accepting or internalizing the stigma.
“Muchas veces uno piensa que si uno le habla a los demás, que ellos pensarán que uno es loco. Entonces a veces uno mismo piensa, ‘¿Será verdad?’ Como que la depresión es un miedo tan fuerte que uno piensa que si es verdad, que uno esta loco.” (Many times you think that if you talk to others, they will think that you are crazy. Then sometimes you think, “Is it true?” As if the depression is a fear so strong that you think that yes it's true, you're crazy.)
In contrast, other participants seemed to resist stigma by directly rejecting terms like loco. Participants also resisted the stigma by adapting their thinking or by educating individuals within their social networks regarding depression and its treatment.
“Yo les explico que lo que estoy tomando es para mi cerebro…. ‘Ve los efectos secundarios, es algo que a mi me hace falta, porque no ando ni drogada ni borracha.’ Le explico que es una falta de células, ‘Es un suplemento que necesito para mi cerebro.’ Así los convenzo.” (I explain to them that what I am taking is for my brain…. “See the side-effects, it's something that I am missing, because I am neither drugged nor drunk.” I explain to them that it's a lack of cells, “It's a supplement that I need for my brain.” That's how I convince them.)
During the focus groups, participants were asked to describe important aspects of being Latino or Hispanic. Common features included being family oriented (familismo), helpful toward one another, and united. These features were reported by 22 (73%), 14 (47%), and nine (30%) participants, respectively. Together, these self-perceived characteristics reflected a collectivist orientation. Other frequently cited characteristics were related to being trabajadores (hardworking), luchadores (people who fight against problems), and aprovechadores (people who take advantage) of the opportunities available in the United States. The combination of these characteristics was reported by 19 participants (63%). Many of these self-perceived cultural characteristics were at odds with the perceived negative attributes of taking antidepressants. For example, the values of being a hardworking person who struggles to overcome problems contradicted the association of weakness ascribed to antidepressants. Furthermore, being family oriented is likely to contribute to ambivalence about accepting the diagnosis of depression or depression treatment when a family member espouses stigmatizing views. In these cases, patients must overcome an additional barrier to treatment.
“Si, pase mucho, sufrí mucho y segundo como que la familia no me entendía. Como que se creían que lo que yo tenía no era nada, changuerías. ¿Entiendes? Entonces, pues yo me sentía mal. Y le explicaba y ellos me decían, ‘Tu lo que tienes que hacer es dejar todas esas medicinas y botarlas.’” (Yes, I went through a lot, I suffered a lot, and secondly, it was like my family did not understand me. It was as if they thought that what I had was nothing, a joke. Do you understand? Then, well I would feel bad. I would explain to them and they would say to me, “What you need to do is stop all those medications and throw them out.”)