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A Hierarchy of Medications?

People who take psychiatric medications long-term are no strangers to stigma, or the threat of it. We perennially face, for example, the question of whether it’s worth risking others’ judgment and the potential negative repercussions of disclosing our conditions — and the fact that we take medication for them.

But you can commit to taking medications long-term and still perpetuate or further the stigma associated with meds. And I don’t just mean that in the sense of keeping your medication regimen secret. Most of us do so in another way altogether that we’re largely unaware of.

The fact is, most people have some kind of internal barometer when it comes to medications – which ones they are willing to take, and which ones they’re not.

In his book “Is It Me or My Meds,” the sociologist David Karp notes that patients “ascribe very different meanings to different medications.” “They carry around in their heads,” Karp writes, “a kind of hierarchy of medications based on their relative acceptability.”

Everyone’s hierarchy is a little different and the reasons variable, but usually it breaks down to this: Some medications seem too heavy-duty, too hardcore, too risky, or too stigmatized because they are tied to disorders, symptoms, problems or even people we know that we don’t want to be associated with.

I think it’s fair to say that very young children don’t make such distinctions, but from my interviews with young adults who began taking medications as children or adolescents, I’ve found that even young teenagers are “more okay” with some meds than others.

For one young woman whose story I tell in my book, “Dosed: The Medication Generation Grows Up,” Ritalin was relatively acceptable – but Prozac, she decided, was not.

Part of this may have to do with how the doctor who prescribed the meds framed them: He diagnosed her with ADHD and told her the Ritalin was to treat that condition. But he prescribed the Prozac as a “just in case” measure, saying many young people with ADHD get depressed about under-performing in school.

After about a year, this young woman stopped taking Prozac. Part of it was that she wasn’t sure it had helped her feel any less depressed. But part of it had to do with the idea of medicating away depression in the first place — she had a certain, romanticized attachment to the idea of being an angsty, messed-up teenager.

Meanwhile, she continued taking the Ritalin because she knew other kids at school who did, had seen how her ADHD had nearly gotten her kicked out of her elite private school, and thought the drugs were justified because they leveled the playing field: In theory, anyway, they were intended to help her perform up to her potential.

Other people I’ve talked to have had the opposite attitude: they were okay taking antidepressants for what seemed like a chronic condition, but less sure they merited an ADHD diagnosis in the first place and uncomfortable with the idea of somehow getting an academic “leg up” from stimulants prescribed for that.

You might think that the longer you take medications, the more comfortable you become taking them, and a sort of “slippery slope” mentality sets in, wherein you figure that you take one medication so you might as well add in another.

This is certainly true for some people, but in other cases, a long history with medication actually reinforces ideas that some drugs are acceptable and others definitely are not.

An episode in James T.R. Jones’ recent memoir of bipolar disorder, “A Hidden Madness,” which I am reviewing for Psych Central, provides an example of this kind of thinking.

After many years on lithium, Jones has an adverse reaction to the drug resulting from long-term use. In its place, his psychiatrist prescribes an atypical antipsychotic drug. He consents to taking it, but reluctantly.

“Antipsychotic” is a scary-sounding term to many people, and Jones is not, as he explains to his psychiatrist, psychotic or delusional (though he had imagined, while manic, that a tree in his backyard and a bus on the interstate were both trying to attack him).

To Jones, this distinction between mania and psychosis is important, and it takes some convincing from the psychiatrist for him to accept that atypical antipsychotics are often prescribed for bipolar disorder (whether or not they ought to be prescribed as often as they are is another matter altogether, and one that’s hotly debated).

Some of Jones’ resistance also has to do with his long history with medication and psychiatric treatment. Decades before, he spent six months in an institution where many patients who were taking older kinds of antipsychotics developed neurological tics and spasms after long-term use. The threat of these permanent side effects justifiably alarms Jones.

I’d love to hear some of your personal experiences with “hierarchies of medication,” and what you think more generally about the idea of some meds being more acceptable to some people than others.

Are these hierarchies understandable, or are they illogical, arbitrary or unfairly biased? What’s your internal barometer when it comes to medications you’ll take – or will give to your child or prescribe to your patients?

Medical pyramid made from multicolored layers of capsules at Shutterstock

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A Hierarchy of Medications?

Kaitlin Bell Barnett

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APA Reference
Bell Barnett, K. (2012). A Hierarchy of Medications?. Psych Central. Retrieved on April 6, 2020, from


Last updated: 26 Aug 2012
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