Though my first encounter with psychiatric medications happened more than two decades ago, I still remember it with immense clarity. I was a 31-year-old doctor in the Department of Community Health at St. Stephen’s Hospital, Delhi. I had a mistimed second pregnancy, which had been very stressful. My postpartum period was also very difficult. I had been unable to eat and felt no hunger. I was crying incessantly and lashing out at my family members.
All this meant that on the 10th postpartum day, I was taken to a psychiatrist.
The psychiatrist was a senior faculty member at AIIMS Delhi. He did not utter a word about what my diagnosis was. This is now corroborated by my husband, who had gone with me as the bystander.
The doctor simply prescribed me a drug and asked us to consult a paediatrician to make sure the drug would not affect the baby through breastfeeding. I remember coming home and referring to my Pharmacology book and being shocked to find that the drug was an antipsychotic. By then, I had no idea what I actually had or why I needed an antipsychotic.
This kickstarted my unstable relationship with the medical system, which remained riddled with mistrust throughout my treatment journey.
I had expected the drug to immediately make me feel better. However, that was not the case. The antipsychotic drug made me drowsy, and I often felt extremely unwell. The doctor who had started me on the medication had not warned me about this effect. It made me worried and distraught. Here I was, a 31-year-old mother of two adorable children, but still feeling utterly empty and unable to participate in my everyday life.
We never missed our appointments with the psychiatrist. I remember crying to him that I missed my job and was worried about career losses. He encouraged me to find a job and guided me towards my next career step. But all that did not inspire my trust in the treatment I was receiving, especially because the effects of the drug itself were confusing.
I eventually distanced myself from the medication completely, though my doctor was convinced it would help me.
After many years of struggling to access care that truly benefited me, I finally found the right holistic care I needed from a team of psychiatrists, psychologists, social workers and community mental health workers. They made me feel at ease and helped me accept my mental health condition.
Looking back, I realise that my greatest challenge was access to trust. The antipsychotic medication was available, affordable and prescribed by an experienced psychiatrist. Yet I gradually withdrew from treatment because the medication made me feel unwell, I struggled to understand my illness, and I lacked the psychological support needed to make sense of what was happening. My distance from the medication reflected a growing distance from the healthcare system itself.
Across the world, millions of people who need effective mental health treatment remain untreated. Research on the global treatment gap has traditionally approached access to medicines through factors such as pricing, production, availability and prescription. I believe there is another dimension that deserves greater attention: whether patients feel psychologically able and willing to engage with the treatment they are offered.
Research suggests that concerns about medicines can contribute to non-adherence and treatment gaps. Studies have documented the scale of treatment gaps is huge - around two fifths of the patients stopped treatment because of their own beliefs and concerns about the need for medications and their diagnosis.
Yet this dimension of access is often missing from discussions about healthcare. This was a gap I began to recognise as my personal experience motivated me to learn from people with similar experiences and from the available evidence.
This dimension can be understood as psychological access to medicines. Psychological access refers to the mental, emotional and cognitive factors—such as social stigma, fear of dependency, concerns about adverse effects, trust, or personal beliefs—that influence whether a person can or will engage with a prescribed treatment. Research on psychological access suggests that access therefore cannot be understood only in terms of whether a medicine exists or is affordable. A person must also feel sufficiently safe, informed and supported to accept and continue treatment.
Where the Health System Goes Wrong
My unique positioning as a medical doctor and a patient in the same healthcare system allows me to see the nuances from both sides.
Doctors often arrive at a diagnosis through a process of clinical judgement. They systematically assess the information that a patient provides against their own experiences of treating similar patients and the guidelines and management protocols available to them. But a doctor's judgement, even when informed by experience and evidence, may not resonate with a patient who has a different understanding of what their illness is.
There is also often an information asymmetry between doctors and patients. Doctors have access to studies and are trained in how to critically appraise them, whereas patients increasingly have access to vast amounts of information online, including misinformation, without necessarily having the skills to assess whether that information is accurate.
This gap between a patient's understanding of their illness and the clinical diagnosis made by the doctor can become a critical one, sometimes resulting in treatment gaps.
When patients have to move from one doctor to another because of travel or other life circumstances, they may also have to rebuild trust from scratch. Conflicting information from different doctors and online sources can create a further trust deficit. Doctors who communicate in highly technical language, do not explain the illness adequately, or do not have enough time to answer questions can unintentionally widen this gap.
Many medications also require individual counselling about how to take them and what side effects to expect.
Medication can sometimes assume an all-dominating presence in a person's life. Once treatment begins, it becomes easy to attribute every discomfort, emotional fluctuation or sense of unease to the medication, even when these experiences may stem from the illness itself or from other life circumstances. This can be especially true when a patient was already resistant to beginning the medication, is unsure about or does not agree with the diagnosis, or has not received appropriate counselling regarding side effects.
Patients may also feel that doctors dismiss the very real side effects they are facing. When these experiences are not acknowledged, the patient can begin to feel that the healthcare system does not understand or listen to them.
Equally, believing that medication alone is the answer can narrow one's perspective on recovery, diverting attention from the equally important roles of psychotherapy, social support, meaningful relationships, healthy living and personal resilience. Recovery is rarely the result of medication alone; it emerges from the interaction of biological, psychological and social interventions.
The consequences of this psychological distancing are particularly evident in psychiatry. Treatment gaps for mental disorders remain among the highest in medicine. Although effective treatments are available, a large proportion of people with mental illness never receive appropriate care or discontinue treatment prematurely. This raises an important question: the treatment may exist, but do patients feel psychologically safe enough to seek it and continue it?
Unless this psychological barrier is addressed, medicines cannot truly be considered accessible.
Establishing Psychological Access for Diseases that Require Long-term Treatment
Unlike diseases such as cough, cold or fever, psychiatric illnesses often require long-term or sometimes lifelong treatment. This is also true of diseases such as tuberculosis and chronic conditions such as hypertension, diabetes and PCOS. Alongside medications, these illnesses may also require long-term adherence to lifestyle changes.
As a medical doctor, I have often counselled patients on the importance of medication and lifestyle adherence, but having been a patient, I also came to understand why people were sometimes non-adherent to medication. It was usually rooted in mistrust of the healthcare system, frustration about an illness remaining uncontrolled despite medications, or the difficulty of fitting together multiple risk factors in order to control a disease.
Fixing this puzzle and fitting the different risk factors together requires good collaboration between doctors and patients.
Patients admitted to hospital with conditions such as hypertension often achieve good control with antihypertensive therapy. However, when they return to their communities, blood pressure may become uncontrolled again. Such relapses can erode patients' trust in both the medication and the healthcare system, reinforcing the perception that treatment is ineffective.
In reality, the medication may not have failed. Patients may simply have returned to an environment that destabilises them, creating a need to adjust treatment further. Persistent psychosocial stressors, environmental challenges, poor continuity of care and lifestyle factors can undermine treatment outcomes. Effective disease management therefore extends beyond prescribing medicines; it requires addressing the psychological and social contexts in which patients live. Without doing so, patients may become psychologically distant from treatments that could otherwise benefit them.
My research on TB medications also yielded an important nuance. When people have seen another family member die of a disease, they may be less likely to continue treatment for the same disease if they develop it themselves. Fear can make people avoid thinking about the disease, while the experience of seeing someone close to them die can create a perception that treatment is futile. Research into TB treatment defaulters in Delhi illustrates how community links, migration and misconceptions can intersect with treatment adherence.
Doctors and practitioners need to understand these nuances before they prescribe medications to a patient.
What we can Learn from Local Practitioners
During my Senior Residency in the Department of Community Medicine at Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, I conducted a qualitative study among healthcare practitioners in Pillangi village, a densely populated settlement located behind South Extension in South Delhi.
Despite the village being situated in close physical proximity to government hospitals and health centres, many residents preferred to consult local practitioners who were not formally qualified in modern medicine. These practitioners, commonly known as “Bangali doctors,” often possessed registrations from little-known medical councils.
Through in-depth interviews and non-participant observation of consultations, we studied the type of care these practitioners provided. A framework consisting of various dimensions of care was used. In the interpersonal dimension, all of them did exceedingly well. They spent time getting close to their clients, even physically close, immediately feeling for the pulse. They listened and counselled by understanding and talking about locally existing beliefs.
For example, the study was conducted during mango season, when there was a locally existing belief that mangoes could cause a bacterial skin infection because they were considered “hot”. One practitioner was observed advising a patient to avoid too many mangoes because they would cause impetigo.
The patients were treated with dignity, which was reflected in the way practitioners addressed them and related to them like family members, as uncles or aunts. They were given enough space to voice concerns and appeared to feel mentally free. Patients also seemed to have considerable faith in the medicines the practitioners prescribed.
The important lesson here is not that healthcare workers should validate misinformation. Rather, these practitioners understood the beliefs their patients already held and communicated within a familiar cultural framework. This congruence appeared to strengthen trust, improve acceptance of treatment and encourage adherence.
Although government hospitals were geographically accessible, many residents preferred local informal practitioners for these reasons. Their preference was not primarily driven by convenience, but by relationships. These practitioners invested time, communicated in culturally familiar ways, respected local beliefs and treated patients like family members. The trust they fostered appeared to influence where people sought care, demonstrating that psychological accessibility can be as influential as physical accessibility.
Psychological barriers to treatment begin long before medicines are prescribed. They are rooted in patients' beliefs about disease causation, expectations regarding illness progression, fears about adverse drug effects, unequal knowledge and power dynamics between providers and patients, judgmental attitudes within healthcare settings, and inadequate understanding of patients' social contexts.
When these factors remain unaddressed, individuals may become psychologically distant from healthcare itself. Improved cultural competence among healthcare providers could help strengthen relationships with patients. The importance of cultural competence in healthcare has also been recognised as an important part of patient-centred care.
So what can we do?
Medication adherence is not merely a matter of remembering to take tablets; it is fundamentally built upon trust. Patients are more likely to continue treatment when they feel respected, heard, involved in decision-making and supported through adverse effects rather than blamed for them. Supported decision-making and therapeutic partnerships can transform medication adherence from an obligation into a shared commitment to recovery.
In today's era of unprecedented access to information, the medical community must actively create and communicate balanced, trustworthy narratives about disease progression, the effectiveness of treatment and the management of medication-related adverse effects.
Long-term adherence often becomes difficult because patients experience side effects without adequate counselling or reassurance. When there is a trusting relationship with the healthcare system, these challenges can be managed collaboratively rather than resulting in treatment discontinuation. Evidence regarding the effectiveness of medicines should be communicated alongside honest acknowledgement of potential adverse effects and practical strategies to manage them.
In India, medical care is often delivered through stand-alone clinics, where there may be limited opportunity for the different professionals involved in a patient's care to work together. More holistic, integrated care could help address this fragmentation.
Conventional discussions on inequitable access to medicines have rightly emphasised high costs, market structures, intellectual property laws and supply-chain barriers. However, these explanations alone cannot account for why effective medicines remain underused even when they are physically available.
Access to medicines should therefore be understood as more than physical availability or financial affordability. True access also depends on whether individuals trust the healthcare system sufficiently to seek treatment, accept it and continue it over time. Psychological access, grounded in trust, dignity and shared decision-making, deserves recognition as an important dimension of access to medicines and as part of the effort to reduce treatment gaps, particularly in mental healthcare.
My journey—as a patient, physician and public health researcher—suggests that access to medicines has another dimension that is easy to overlook: psychological access. Medicines cannot improve health if people fear them, distrust them or disengage from the systems that provide them. Building trust, promoting supported decision-making, acknowledging patients' lived experiences and delivering holistic care are therefore not optional additions to healthcare. They are prerequisites for effective treatment.
Recognising psychological access as an important dimension of access to medicines may help narrow one of the most persistent treatment gaps in global health.
Edited by Christianez Ratna Kiruba
Image by Gayatri
