Anthropology & Medicine

Vol. 17, No. 2, August 2010, 173185

Self-compliance at Prozac campus

Kelly A. McKinneya* and Brian G. Greenfieldb
a

Department of Humanities, Philosophy and Religion, John Abbott College, 21,275

Lakeshore Rd, Ste. Anne-de-Bellevue, Quebec, H9X 3L9 Canada; bDepartment of
Psychiatry, Montreal Childrens Hospital and McGill University, Canada
(Received 9 April 2010; final version received 12 May 2010)
This paper focuses on psychiatric medication experiences among a sample
of North American university students to explore a new cultural and social
landscape of medication compliance. In this landscape, patients assume
significant personal decision-making power in terms of dosages, when to
discontinue use and even what medications to take. Patients carefully
monitor and regulate their moods, and actively gather and circulate newly
legitimated blends of expert and experiential knowledge about psychiatric
medications among peers, family members and their physicians. The
medications too, take a vital role in shaping this landscape, and help to
create the spaces for meaning-making and interpretation described and
explored in this article. In concluding the article, the authors claim that two
popular academic discourses in medical anthropology, one of patient
empowerment and shared decision-making and the other of technologies of
self and governmentality, may fail to account for other orders of reality
that this paper describes orders shaped and influenced by unconscious,
unexpressed and symbolic motivations.
Keywords: psychiatry; ethnography, narratives

This paper will focus on psychiatric medication experiences among North American
university students to explore a new cultural and social landscape of medication
compliance.1 In this landscape, patients assume significant personal decisionmaking power in terms of dosages, when to discontinue use and even what
medications to take. Patients carefully monitor and regulate their moods, and
actively gather and circulate newly legitimated blends of expert and experiential
knowledge about psychiatric medications among peers, family members and their
physicians. The medications, too, take vital roles in shaping this landscape, creating
varied spaces for meaning-making and interpretation. Moreover, the symbolic effects
of these medications are no less important than any ostensibly isolated
neurochemical properties they possess.
Medication compliance in this landscape will be understood in terms of two
frames of reference. One frame comprises the institutionalized privilege of
psychopharmaceutical interventions over all other treatments for the chronically
mentally ill a population of patients with psychotic disorders who have entered,
and re-enter, the public and community mental health systems. For this group of

*Corresponding author. Email: kelly.mckinney@johnabbott.qc.ca

ISSN 13648470 print/ISSN 14692910 online
2010 Taylor & Francis
DOI: 10.1080/13648470.2010.493604
http://www.informaworld.com

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K.A. McKinney and B.G. Greenfield

patients, the goal of improving medication compliance, with medication compliance

taken to mean anything from patients compliance with written prescriptions to
mental health workers recommendations for medication usage, virtually defines care
(Estroff 1981; Rhodes 1991; Applbaum 2009). In this context, psychiatric medication
non-compliance is considered the most powerful cause of decompensation or relapse
for patients with psychosis (Applbaum 2009) and is associated with increased rates
of involuntary detention, longer hospital admissions, and slower recovery from
symptoms (Day et al. 2005, 717).
Patients with psychotic disorders, including schizophrenia and schizoaffective
disorder share a medication non-compliance rate of approximately 50% with
patients suffering from other long-term illnesses, such as asthma, hypertension, and
diabetes (Pound et al. 2005). As one psychiatrist with whom one of the authors of
this article spoke described her medical training, We were taught that most patients
would be non-compliant. Our goal was to figure out not who but how each patient
was non-compliant in their [sic] own way. Researchers have identified scores of
variables related to medication non-compliance including the quality of the patient
doctor relationship, side effects, and illness beliefs (Pound et al. 2005).
In contrast, individuals with less pernicious mental conditions than psychosis,
(e.g., garden variety anxiety disorders and depression) who possess greater cultural,
social and monetary capital, and who are not constrained by legal and other coercive
measures to enforce medication compliance, do not have medication experiences
organized around compliance to the same extent or in the same manner. However
much, therefore, the social grid of medication management (Longhofer, Floersch
and Jenkins 2004) a complex system of interaction composed of actors including the
patient, psychiatrists, family members, therapists, pharmacists and financial
stakeholders (Applbaum 2009) that shapes medication experiences of patients can
include the same actors for university patients as for those with chronic mental illness,
the grids driving energy is less organized around medication compliance per se, with
relative power also distributed more diffusely or concentrated differently in the grid.
The second frame includes models of medication compliance for disorders that
have greater scientific validity as biological illnesses than many mental health
conditions. There are no biological markers, specific etiologies, or widely efficacious
biologically-based interventions for many mental disorders, and thus diagnosing and
treating these conditions is frequently marked by uncertainty, trial and error, and
profound physician variability. Moreover, physicians facing a patient with depressive
symptoms have a cornucopia of at least 20 antidepressants to choose from, most of
them me-too drugs, and only a 60% chance of getting the medication right first
time. Many patients respond only after the second or third medication is tried
(Schuyler 2009). Further, for chronic and severe disorders such as diabetes, for
example, insulin compliance can be a matter of life and death. For mild depression,
much less is at stake with regards to antidepressant compliance. This opens
treatment decisions and compliance practices to greater fluidity and open-endedness
for mental health patients the group interviewed for the present study and for
their doctors.
This papers exploration of what is provisionally termed the self-compliance
landscape will distinguish itself from the genre of medication compliance
improvement studies for two reasons: (1) the data demand a new framework for
understanding compliance that in turn challenges conventional concepts of

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improvement and (2) given that the pharmaceutical industry is not only in the
business of helping people, but that its profit motive drives the creation of new
patients who will take psychiatric medications, anthropological endeavors to
understand the conditions for medication non-compliance must be cautiously
undertaken. This is especially so since the industry actively targets medication
compliance itself as a site for increasing profits (Applbaum 2009). Rather, this paper
will examine several patterns of medication use and symbolic practices that speak to
medication compliance but also illuminate more generally the psychiatric medication
experiences of a new generation.

Methods
The data for this study are drawn from interviews with twenty-two 1924-year-old
university or post-university young adults living in Montreal, QC.2 For inclusion,
participants had to have taken, or were currently taking, a psychiatric medication
for a mental health problem. The interviews were conducted in English from 2007
to 2008. A significant number of the participants suffered from mild to moderate
depression and took an SSRI antidepressant. It is important to note that these
participants did not suffer from chronic psychotic disorders. The distress this studys
sample faced is considered treatable through psychotherapy and for many of the
participants was identified as situational or transient. Many depressive episodes seem
to have a natural life span and will remit on their own. Further, unlike antipsychotic
medications, which have sedating and other pronounced effects on users, some
evidence suggests that the most commonly prescribed antidepressants do not work
significantly better than placebo for mildmoderate depression and that only 20
30% of patients who try an SSRI will respond positively to them (Kirsch et al. 2009).
The quality of distress of this sample and the pharmacokinetics of antidepressants
therefore also contribute to a more ambiguous and fluid landscape of compliance.
Other participants in the study identified their conditions as anxiety, panic attacks,
bipolar disorder, anorexia, bulimia, cutting, substance abuse, and attention deficit
disorder, and were taking or had taken medications other than antidepressants,
including Xanax (an anti-anxiety medication) and Adderall (a psychostimulant). Two
had been hospitalized for psychiatric reasons. Nearly all had been engaged in some
type of psychotherapy or counseling at some point. Many of the participants were
academically high achieving despite reporting significant emotional suffering.3
Understanding the psychiatric medication experiences of this population has
important social value. University students represent a rapidly growing population
of psychiatric medication users in North America. At Harvard University in 2002,
for example, more than 1000 of the approximately 2000 students who visited the
university mental health center received a prescription for an antidepressant.
According to a 2003 American survey of 283 colleges and university counseling
centers, 95% reported an increase in the number of students taking psychiatric
medications from previous years, with 1820% of students seeking help at these
centers already taking a psychiatric medication (Young 2003). Jeffrey Young (2003)
has dubbed this phenomenon, Prozac Campus.
In the next section, several case studies that most clearly articulate important
features of the self-compliance landscape will be described and analyzed. These case
studies suggest three major domains where self-compliance is enacted: (1) self-dosing;

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(2) family prescriptions; and (3) effects: placebo and side. Following this section will
be a discussion with concluding remarks.

Case studies
Self-dosing
When first interviewed, Max, a 20 year-old art history major with anxiety and
seasonal depression, was taking Wellbutrin XL (a newer antidepressant in a different
class than SSRIs). With strong encouragement from his parents, he ambivalently
decided to see his mother and aunts psychiatrist after he became a complete wreck
during a break from university:
I think I was very skeptical, and I was going really because my mom wanted me to, but
also at the same time I realized that I could be in a better place, and my situation and my
feelings and my thoughts could be better, like, that I could be happier. So I think I was
willing to give it [medication] a shot, but I even talked to him [the psychiatrist], and I
said, Im not really sure I believe in this. Whats your stance on therapy versus just
prescribing medications?

The doctor helped Max feel comfortable with the idea of medication and gave him
some discretionary power in deciding his own medication dosage:
I think that the antidepressant Im on is pretty much the lightest, and he [the
psychiatrist] started me off on the lightest dose and said that, if youre not impressed
with the difference, go up to two pills a day instead of one . . . Im still on the lowest
dose. I probably could be high as a kite4 if I wanted to, which would probably be very
nice. Im still a little skeptical of it. I think I will double the dose in winter.

McKinney interviewed Max again, and he recounted his medication use since the
first interview almost two years before. Overall, Max felt that the medications
worked well for him. The summer after the first interview was a very happy
summer. However, in the fall, Max anticipated the heavy darkness of winter as his
feelings of depression started creeping back in. He was no longer feeling impressed
with the effects of one pill, so he took it upon himself to double his dose before the
depression took over. During this period, Max could not get himself organized
enough to get his prescription refilled (his prescription is from the US, he lives in
Canada, etc.) and went off for two weeks. Between what he interpreted either as the
withdrawal and the depression coming back or both, he felt horrible and went
back on medication as soon as he got his new prescription. After several months,
Max went off again when he and his doctor decided together that many of his
situational life issues were resolved and a summer without external torment
beckoned on the horizon.
Max kept all the extra pills he had accumulated over the two years when he only
took one Wellbutrin but had been prescribed two: I didnt throw the stockpile away
because its not like my life was cured. He took those pills with him while traveling
and working in Europe after graduating from university. His family, worried about
his mental health, suggested it, and he didnt think it was such a bad idea. Within
three days of returning home from Europe, he started weeping and falling apart
because of the major life crisis he was experiencing, post-Europe, unemployed, and
with no life plan. Max decided to go back on Wellbutrin and to take not one, not
two, but three a day to wash away the pain, which he said was completely
irrational and symbolized the desperation he felt. After a week of insomnia, Max

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said jokingly, I realized I took an extreme does of an upper, like it took me a whole
week to figure it out . . . but maybe it was good because sleep deprivation is good for
depression, right?
Max reported that at least three times he has started up his meds again for one or
two weeks at a time, whenever he starts feeling particularly anxious, unfocused,
confused, and self-loathing. On the one hand, he says he is very flaky about them
[the meds] while on the other, he says, I know them and know myself well enough
that I dont need to see the doctor, at least while I still have some left. He also says
he knows that it takes two weeks for the medication to work, and that before the
end of the two-week period it is probably just the placebo, but he believes he still
feels better taking them for that short period of time: Even if I am not consistent
with them, maybe it still helps because of the placebo . . . Its also like I am saying to
myself, I am doing this, I am taking control of my life. Recently, Max again has
found himself in another major life transition and decided to start up on the
Wellbutrin: I guess I have self-medicated enough to know a little bit about what I
am doing . . . my mood has been holding me back and I need to establish some goals
and myself right now and this I hope can give me an edge.
Elinor, 21 and an education major, suffered from a self-diagnosed (or brotherdiagnosed) unspecified sleeping disorder that, in the past, doctors had attributed to
stress. Her brother, who takes medication for anxiety and narcolepsy, is in medical
school and has his little emergency kit. He thought his sister should try Ritalin for
her daytime sleepiness and gave her some from his kit. Elinor didnt like it (nor did
he when he tried it) so he gave her some modafinil5 instead. After taking modafinil
for a short period Elinor had a seizure that brought her to the care of a neurologist:
I spoke to a doctor at the university hospital, a neurologist . . . And I was like I, okay,
Im going to be an adult so hell take me seriously about this. So I was just like, listen,
you know, I just told him what was up and like how I was feeling. And he was just like,
let me just look it up and make sure that it cant induce any more seizures . . . And I only
had one, it was a freak thing . . . but he just wanted to be safe. And so he wrote me a
prescription, Ive been on modafinil like before my brother was giving it to me. So it was
almost like I sort of had a prescription but not really. [Laughs]

Elinor takes the modafinil when she decides she needs to be alert and focused, e.g.,
for exams. She thoroughly read the drug description that came with her prescription
and her brother has continued to act as her drug guide and counsellor:
I mean, you know, reading the description, like the description that comes inside of it,
its fairly safe. Its nothing even remotely close to like the potency of like taking an
amphetamine like Ritalin. So I took like one or two. It depends on how you feel. There
was no like, you can only take like three per this many amount of hours. It was just like
flexible.

Both Max and Elinors stories portray how they as patients are granted and assume a
significant amount of latitude with their medication intake and dosing: its flexible.
When Max was asked about what he imagines his doctor would think about his
inconsistent, self-determined use, he said, He probably wouldnt care that much. He
might not think it was such a good idea though, but he would just talk to me about
it. With Wellbutrins introduction into his life, Maxs attention to his moods and
thoughts became imaginatively intertwined with the pill. How am I feeling? What
will I be feeling in the future? Should I take more? Should I stop? Should I start
again? He is aware that his medication use is flaky but he also feels he can

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legitimately take the meds based on the authority of his own self-knowledge and
experience, even if that knowledge includes the possibility that the medication has
greater symbolic power than actual neurochemical efficacy in the way he has more
recently used it.
Evidently, Elinors doctor took her seriously when she explained to him how she
had been taking modafinil for the past eight months without a prescription. Here,
a 21 year old with no formal medical training has not only the expertise but the
authority to have a dialogue with her physician about her condition and her selfinitiated pharmaceutical intervention. Elinor also enjoys a relationship with a
medical consultant outside the conventional purview of care who speaks as an
authority as her older brother, a medical professional in the making, and as a
medication consumer himself.
Today, actors other than clinicians, including family members, friends, and other
users are stretching the spheres of influence (and compliance) into historically new
shapes. Elinor has a strong interest in informing herself about her medications, not
necessarily because she mistrusts the doctor, but because she feels responsibly
entitled to know and manage her medications and her own body. Other participants
in the study also consulted the internet for information, sometimes because they felt
the doctor did not give them sufficient important information (for example, about
side effects) but also because this is part of what it means to perform educated and
responsible self-care and consumerhood as a psychiatric medication user today.

Family prescriptions
Natalie, 22, has lived for several years with, what was at one point, a life-threatening
eating disorder as well as anxiety and depression, and with the help of Prozac and
several other medications (along with her psychiatrist, boyfriend and cat) these have
become more manageable for her. Against great odds, Natalie left her Southern
working class, Christian fundamentalist family to become a student at an elite
Canadian university. Medications play a manifold role in Natalies life, but here the
focus will be on what mediating role medications play in her relationship to her
family.
Like, I think the way I grew up completely justifies being on the medication . . . I have a
lot of anger and bitterness and resentment . . . [because I take Prozac] my grandparents
are scared of me . . . it means I have a volatile personality; at any moment I could just,
like, go and just start doing crazy things or I could just brandish a weapon or something
like that. Like, I could just be insane. What they dont realize is that they should be on
Prozac too. Theyre pretty crazy. [Laughs.]

According to Natalie, Prozac communicates. It tells her family that she is crazy and
dangerous, perhaps even more so than any of the behaviors that indicate she is not
well, thus functioning as a symbol of opposition and resistance to the family she
perceives as the source of her trauma and troubles. Yet at the same Prozac
symbolizes her identification with them they should be on it, too. But even if they
were, Natalie believes she would still be differentiated from those at home, in class,
culture, and emotionally, because of the responsible way in which she takes it:
I mean, personally I think that theres a huge problem with over-prescribing
medications for psychiatric problems, but I dont really feel like Im a drug-seeking
individual whos looking to mask a problem . . . I dont just go to a GP and say, hey, give

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me some Prozac, and take it irresponsibly. I do what I need to do . . . I know at home no

one will even see a psychiatrist. They all go to family doctors and get psych
prescriptions, usually SSRIs, from just a medical doctor, a regular medical doctor who
has no experience whatsoever with SSRIs. And you know, theyll drink beer or
something like that with them when theyre not supposed to, they stop them suddenly
without titrating them, they do all sorts of irresponsible things and the medical doctors
arent telling them how to take them responsibly.

Like other young adults interviewed in this study, Natalies perceptions and
expectations about psychiatric medications were framed by collective discourses
defining psychopharmacologys place in and impact on contemporary society. In
particular, a skeptical, at times even critical, take on psychiatric medications have
become part and parcel of life in that real and metaphorical place called Prozac
campus, shaping the ways in which young adults experience psych meds. Here, for
instance, Natalie understood her experience through the social critique of overprescribing. However, popular broad and sometimes polarizing critiques become
increasingly complex and sometimes even irrelevant in the everyday lives and
symbolic and moral worlds of the people who take psychiatric medications. In the
case of Natalie, she is motivated to stay on Prozac and to take it responsibly, for
several reasons. One, it simply helps her feel better. More surprisingly, Prozac
enables her to re-position herself with regard to her family; Prozac provides her with
a way to express her rage, symbolizes her separateness from her family and serves as
a vehicle for elevating herself from her familys lower social class origins.
Steven, 23, a commerce major, has suffered from depression, anxiety and
alcoholism. He took Paxil (an antidepressant) as a child and Xanax (an anti-anxiety
medication) as an adult. Steven described a lousy childhood, part of which included
his recently deceased mother making him take Paxil for the first time when he was
12. For Steven, the Paxil represented a great dilemma. He was extraordinarily
unhappy at that time he took the Paxil. It did help him feel much less depressed and
withdrawn, but his mother also used the Paxil to create and reinforce the perception
that Steven was sick, abnormal, and weak. By taking the Paxil, Steven also found
himself enlisted into what he would concur was an unhealthy identification with her.
Further, the Paxil served as a divisive tool his parents used against one another in
their deteriorating marriage:
She [mother] was a huge believer in counseling and psychology/psychiatry. She had, I
dont know how many therapists in her lifetime. And they ended up putting me on this
drug called Paxil apparently its pretty common and my mom just loved this drug, I
dont know why. And it did make me feel a lot better when I took it consistently. I never
really liked the idea of taking it, though. She took a huge assortment of prescriptions,
not always as instructed. She mixed pills that werent supposed to be mixed and took
them irregularly . . . she was always at me to take this drug Paxil, and even if I asked
something pretty matter-of-fact that wouldnt indicate to most people that I was
depressed if I asked if a friend had called shed say something along the lines of, Oh,
Steven, you need to take your Paxil. You sound so concerned about your friend calling,
or something like that, and just make a big deal out of it and tell me I should take Paxil.
And I remember my parents arguing about it and my father saying things along the lines
of, just because you take ten prescriptions a day doesnt mean everybody should, and
stuff like that.

Steven began taking the anti-anxiety medication during university while going
through a stressful period; his mother died and his father and stepmothers cruelty
toward him reached new depths. His prescribing psychiatrist was the first person,

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other than his friends, that he said truly helped him and he was faithful to the
medication regime she prescribed. The drug unequivocally enabled him to feel much
more relaxed, less worried and anxious, and to sleep. No longer the ambivalent
object of his Paxil years, this time the medication acted as his ally and as a bulwark
against the destructive behaviors of his father and stepmother. It was also identified
with his psychiatrist, the good mother. Steven knew he had the freedom to take more
of the Ativan she had prescribed if he wanted, but he chose not to.
There were times when I was taking a reduced dosage, and I wished I could take more
and in theory I couldve, but I always obeyed the dosage. But I trusted the psychiatrist
enough, that I followed her instructions and didnt deviate from them. So when she
indicated I was to take less, I took less. I wished I could have had more, but I didnt take
more.

Debbie, 19, a media studies major and soccer player, took Paxil, too and Ativan, not
only to manage panic attacks and to control her anxious, depressed feelings, but less
directly as a gift to her parents. Part of what motivated Debbie to take the
medication was Paxils capacity for assuming this role; Paxil could strengthen the
bonds and sense of cohesion between family members through smoothing Debbies
affect and alleviating her parents guilt. While Debbie was battling panic attacks
in high school, her parents were going through a painful divorce:
Because another thing that was anxiety-inducing, my parents were splitting up, and it
really helped me get through that and be able to deal with it and not to cry so much
about it, and it also helped my parents feel like they werent wrecking my life as much
because before I went on medication I was really upset about it all the time.

In all of these cases, the use of psychiatric medications mediates and shapes the
psychic and social field of the family, and the family in turn influences and molds both
medication use and experience. An added twist to this dynamic constellation emerges
when other family members, particularly parents, have their own personal histories
with psychiatric medications. This is not an uncommon (Oldani 2008, 2009) trend and
emerged several times in the stories the authors heard. These stories also illustrate
how medications can function as symbols for translating and reordering familial
disorder and rupture, moving pain from the order of the inexpressible to an order of
intelligibility and continuity (Levi-Strauss 1967). For Natalie, however, taking
medication disrupted the order promised by the image of phamily harmony that
Oldani (2008, 2009) suggests psychiatric medications make possible in contemporary
life, to create instead a new order of family disharmony under her perceived control.

Effects: placebo and side

Melanie, a 19 year-old communications major, had been battling eating disorders
and depression since she was in grade 7. Several months before the interview, she
visited a campus mental health clinic, began psychotherapy and started taking Zoloft
because she was deeply depressed. Melanie feels the Zoloft has helped give her much
more energy and reduces her need to cry all the time.
When she first started taking the medication, an interpretive space opened up
in which Melanie needed to make sense of suicidal feelings:
It was like a low dose so it wouldnt . . . the symptoms wouldnt be that strong, and they
actually started me on half a pill first, half a pill a day . . . I didnt go on a full pill until

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recently because when I started going on the half a pill the symptoms were really strong
because I started feeling really, like . . . I wasnt feeling the best . . . I started getting
suicidal thoughts . . . I had suicidal thoughts before the anti-depressants, like in high
school, but this time it was really persistent. And I knew that that was a side-effect but it
kind of worried me, so I went off them for a few days and then I went back on them,
so . . . But now I think Im, like, I was ready to take, like, the full pill a day, and so its
just another personal choice- . . .

Here, Melanie uses the word symptoms to describe side effects, a choice of words
that suggests how interpretively difficult patients might find it to distinguish between
the drugs iatrogenic effects from their own symptoms. This interpretive space also
opens when patients begin to withdraw from the medications. Although
antidepressants are considered non-addictive, withdrawal from them or missing a
dose can send patients into a state of sometimes severe disequilibrium. Many wonder
if this is a visitation of their symptoms or an effect of not taking the meds. Steven
spoke about what happened to him when he missed a dose of Paxil:
I felt very vulnerable when I took it, because especially being only twelve it just
amazed me that forgetting to take a tiny little pill could make me feel so awful the next
day. That made me feel vulnerable and made things seem like, I guess it made everything
seem kind of trivial, because my whole life changed so much when I took it that it made
the external things seem kind of trivial, because no matter what I did on a given day
how much I enjoyed the day depended so much on the pill, so at the time it made
external things seem kind of trivial, because I could do something that most kids would
find fun, and if I hadnt taken the pill, I would feel terrible. If I had taken the pill, I
could do something that seemed kind of boring, and Id feel pretty good.

During Stevens interview, he even speculated that perhaps this was deliberate, that
somehow the pharmaceutical companies had created medications that made patients
so vulnerably dependent that to be non-compliant or discontinue use would disrupt
patients already tenuous sense of well-being. For Steven, tremendous costs were
attached to the pills benefits: they had the paradoxical effect of disempowering him
psychologically, and dimmed the relevance of the external world to him.
When asked about how she knew about the possibility of suicidal ideation with
her antidepressant, Melanie explained:
They have the warning sheet and it had a list of symptoms, and it had, like, warning,
medication may cause suicidal thoughts in the transition of . . . starting to take the antidepressants. And then I didnt want to be like, oh, the second that I see the symptoms
that I assume that Ill get the symptoms, so I kind of calmed myself and was like, no its
nothing, I dont want to get freaked out, but the thoughts kind of persisted for a few
days, and then I went off the anti-depressants. And then I talked to my psychologist and
she just said to take it easy and to go on when Im ready, and then when I went back on
them the symptoms just kind of . . . they werent as bad, like the suicidal thoughts and
other symptoms. But I was getting the physical symptoms. I got really thirsty, my
sleeping patterns werent the best so I thought maybe it wasnt just in my mind . . . I also
told [the psychiatrist] about the suicidal symptoms and she said that if it ever comes
back, they have an emergency center there or something, like a late night thing. They
were also worried it was because I read the information . . . they said maybe its because I
researched all the symptoms and things like that that, maybe it got into my head . . .

Melanie not only read the package insert, but educational (school) and commercial
interests (television) had constructed representations, expectations and beliefs that
strongly prefigured her medication experience:
Well, I basically knew about the symptoms before because in junior high and in high
school in our health classes I researched these things for projects and I just

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knew the basics. And I knew that there would always be side effects and I wasnt
surprised with the minor side effects . . . Even the suicidal thoughts I wasnt surprised,
because I heard about it, like, on TV, but I thought it was really, really rare, and even
my psychologist said its really rare, so that they were kind of worried when I had those
thoughts. So when I researched it again on the internet just to kind of like remind
myself, it wasnt anything that made me think, oh I shouldnt go on them. It was just
kind of . . . just for me to know, like, in case these symptoms do occur, like, I would just
know that it was because of the medication, so it wasnt something that kind of
prevented me from taking them.

For Melanie, arming herself with more information about her medication was not
necessarily better, in the sense that information could itself create the possibility of
side effects. She understood this side-side-effect and considered it before the
psychiatrist and psychologist suggested it to her. Simultaneously, knowing the sideeffects beforehand normalized them and was reassuring to her when she did
experience them, and the minor side effects worked to convince her that she could
attribute her suicidal ideation as well to the pills. Melanie decided to go off the
medication and then go back on it, increasing the dose to one pill, based on her own
subjective understanding about how the pills were affecting her. This was not just a
medical decision. She was also exercising responsibly her freedom to make her own
personal choice.

Conclusion
In contrast to patients with psychotic disorders, whose illnesses are often hallmarked
by lack of insight and denial of having a mental illness (which in turn are believed to
produce medication non-compliance, which in turn causes relapse), this study found
that no matter what drugs or diagnosis to which participants in this study
subscribed, all to a certain extent experience their suffering in biomedical terms. For
this group of med users, taking a psychiatric medication is integral with swallowing
some kind of biomedical explanation for their condition. Most of the participants
interviewed thus understand the relative effectiveness and side effects of their
psychiatric medications or have some vague notion about chemical imbalances and
the brain. However, this was only a small part of their experience. By agreeing to
take a psychiatric medication, these patients assume a role in a culturally-mediated
drama, powerfully staged by consumer culture, pharmaceutical interests and medical
institutions and the pathologies, cures, and possibilities of certain desires they shape.
Giving force and energy to this drama are the psychiatric medications themselves,
those tiny, round, oval and square object-things that course in, through and between
bodies, bursting with rich symbolic capacities and meaning-making potential. The
vitalizing energy of the pills derives from many sources: from their chemical (and
symbolic) action on mood, consciousness, and perception those elements forming
the very core of subjectivity and selfhood; from the ways in which they are socioculturally working to transform our dearly held concepts of what it means to be
human (Williams 1997); and because these medications also can move people
into establishing, avoiding and breaking off social relationships (van der Geest,
Whyte and Hardon 1996, 157).
In this complex field of relationships, fluid spaces of uncertainty, ambiguity and
ambivalence open, with shifting valences of importance. These spaces demand
interpretation and a meaning-making response. This study is particularly interested

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183

in how those spaces are created and managed by medication users. If, for example, a
user perceives a side effect of a medication, how will she interpret it? Will she wonder,
Am I just making it up? Does a side effect mean that the medication is working? Is
my side-effect the result of reading about side-effects? Doctors and pharmaceutical
companies may think of these spaces in terms of efficacy, algorithms, adverse events
and compliance, while patients are confronted with more complex dilemmas. Its the
anthropologists task therefore to listen to the discrepancies between different
narratives of compliance and to discover different ways to talk about and perceive
the role of medications in peoples lives.
To conclude, as this paper has shown, across the psychiatric diagnostic menu,
conceptualizations of and social relations shaping expertise, authority, education,
surveillance and monitoring that underpin the traditional problem of medication
compliance relations usually critiqued in terms of hierarchy, coercion, exclusion,
delegitimization and patriarchy have been reconfigured at Prozac campus in such
ways to suggest that anthropologists need to develop new languages to describe what
is happening. Two existing languages can do some of the work of analysis, but also
come up against their own limits. First, one could turn to the new discourses of
shared-decision making, patient empowerment, concordance, and patients as
consumers, and analyze and assess self-compliance in terms of that ethic. This
ethic however presupposes certain notions of power, emancipation, and progress
that may too easily reinforce and coincide with a neoliberal ethics that creates new
structures of power, anxieties and pressures (Moncrieff 2006). Alternatively, one
could invoke Foucault and neo-Foucauldian theories of biopower, governmentality,
and technologies of self (Rose 1996; Foucault 1997). Indeed, the provisional term,
self-compliance, implies some sort of technology of self, in which the self is
simultaneously shaped and called upon to comply to an ethics of self-empowerment
entailing at once shifting hierarchical and vertical relationships with another (e.g. the
prescribing physician) that is mediated by neurochemicals. This analytic path could
be pursued and elaborated much further than will be done here, but the more
important point is thus: an analytic of governmentality can make the links between
pharmaceutical companies, medical systems, schools, doctors and patient subjectivities, which are constituted through and give rise to particular socio-cultural and
political-economic structures, intelligible. Although commodious and illuminating
theories for these types of phenomena, in their current popularity they have also
succumbed to a certain sort of reductionism. In fact, they may fail to account for
other orders of reality that this paper has ethnographically described, orders shaped
and influenced by unconscious, unexpressed and symbolic motivations, thoughts and
desires that make these links uncertain and ambiguous, orders that, however, do in
real and material ways help constitute new kinds of persons (Hacking 1999).

Acknowledgements
Funding for this project came from a 20062009 Social Sciences and Humanities Research
Council of Canada Standard Operating Grant. All research was conducted with ethics
approval from relevant institutions. The authors thank Michael Oldani and Kal Applbaum
for their efforts in making an interesting American Anthropological Association Annual
Meeting panel into an even more interesting special journal issue. In addition, the authors
appreciate the comments of anonymous peer reviewers, and extend a special thank you to

184

K.A. McKinney and B.G. Greenfield

Laurence J. Kirmayer, Aidan Jeffrey and Devon Proudfoot whose contributions to this
project have been invaluable.
Conflict of interest: none.

Notes
1. In this article the terms compliance and non-compliance will be used rather than
concordance or adherence in keeping with the title of this journal issues theme.
2. Interviews conducted were based on the Teen Subjective Experience of Medication
(TeenSEMI), a semi-structured interview instrument (Floersch et al. 2009), which the
authors modified to accomodate and reflect the experiences of college-age participants.
The present study is embedded in a larger ethnographic study that includes interviews
conducted with teenagers ages 1418 about their medication experiences, their parents,
and mental health practitioners, and from participation in and observations made of a
Quebec hospital emergency mental health team during that time period.
3. A campus mental health psychiatrist with whom one of the authors spoke found this
incoherence or disconnection troubling. He felt that some of the high-achieving students
were less psychically integrated than students who were both emotionally and
academically suffering.
4. Later in the interview, Max was asked to clarify what he meant by high as a kite. His
reply: I dont think that I would feel that way really. Its more like, instead of waking and
going, Oh God. Why didnt you take me in my sleep, Lord? Why do I have to face
another day? being like, okay, I have to do this and this today, and Im going to get
through it. What do I have to do first? Instead of, ohhh whats happening? I guess
having the energy and the motivation to tackle the day would be the best way to put it.
Another participant used illicit drug slang, I felt blazed to describe her experience on
an antidepressant. Patients usually do not want to feel high or blazed when they take
prescribed psychiatric medications.
5. Also known as Provigil, this stimulant is popular as a neuroenhancer especially in
England.

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