Dealing with overwhelming life situations - young people’s experiences of becoming depressed

Depression is one of the most common and most debilitating health problems of today (1). The etiology of depression has been ascribed to a multitude of factors and a dynamic interplay between them. They range from genetic factors (2) to more contextual socio-economic challenges, interpersonal stress (3), exposure to traumatic events (4) and social exclusion (5). Gender stereotypes and societal norms may also contribute to the onset of depression (6,7,8,9,10,11). Recent studies indicate that the incidence of depression is increasing in young people (12,13,14). From 2006 to 2018 self-reported mental distress in Sweden was highest among 16–29-year-olds, an age group that also showed the highest yearly increase of depression (15). Among people who develop their first depressive episode in adolescence the risk of subsequent depressive episodes is increased threefold (16). Early onset depression presents with high psychiatric co-morbidity and it is related to several negative outcomes such as substance abuse (17), poor academic performance (18) and suicide (19, 20).

It has been shown that the subjectively perceived reasons for getting depressed impact how patients manage their condition (21). The subjective understanding of the suffering and patients’ narratives and meaning making impact both compliance to treatment and help-seeking behaviours (22, 23). Research has also highlighted how adults with depression perceive their depression onset, but less is known about young people. There is some evidence that young people attribute their difficulties to both negative environmental circumstances such as traumatic experiences and family challenges and internal factors including genetic factors and personality (6, 7, 9). The literature also reports that some young individuals find it hard to make sense of their depressive symptoms and hence are unsure of why they became depressed (6).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is applied as the principal authority on psychiatric diagnoses. It has low diagnostic validity in this age-group, especially for depressive disorders (24,25,26,27). The DSM-5 is based on signs and symptom criteria, it largely discounts the etiology of depression, and it neglects the subjective understanding of why a person gets depressed.

With this approach there is a risk of missing or minimizing important clinical information and both developmental and contextual factors may be crucial for therapeutic alliance and patient validation. In this qualitative study we wanted to make the voices of young people with depression heard.

Here follows an elaboration of the results presented in text, and codes are compared within and across categories/subcategories. Quotations are included to illustrate subcategories and support analytical claims. The quotations have been translated from Swedish to English [translator’s clarifications are bracketed].

This qualitative study aimed to explore young people's experiences of becoming depressed. Semi-structured interviews were performed to gain an increased understanding of the perspectives of young people with depression in Sweden. Our study suggests that the young people in our sample attribute their depression to several reasons that have been presented in the different categories. We interpret the participants descriptions to indicate that they were dealing with an overwhelming life situation. The results are in accordance with previous publications, where contextual factors such as childhood trauma (e.g. abuse, domestic violence and bullying), family challenges (e.g. parental illness and parental separation), and losses (e.g. death of loved ones and relationship/friendship breakups) have been described as contributing to depression in young people (2,3,4, 6, 31). Previous studies have also identified individuals that ascribe symptoms to biological factors (31), this was however not detected in our sample.

In our study participants described their depression as related to their relational context and to events and circumstances that they had been subjected to, and not just a randomly appearing mental disorder. This is in line with recent research indicating that contextual factors systematically outperform neural metrics in predicting adolescent depression (32). The categories “Being subjected to violence”, “Suffering separation and loss”, “Feeling abandoned”, and “Feeling burdened and vulnerable” all reflect such contextual circumstances. Only the subcategory “Feeling lonely, inadequate, and fragile” contained codes related to internal factors, and still this subcategory reflected results of mainly contextual factors. Hence, the participants’ understanding of why they got depressed was almost exclusively ascribed to stressful life events and their stories highlight the variety of struggles that young people with depression have had to deal with in their everyday life. Participants described the presence of e.g., violence, neglect, bullying and having too much responsibility, and placed the blame for their depressive symptoms on these events and circumstances. In addition to these stressful contextual factors, the participants also described a lack of support. Both the category “Feeling abandoned” and the subcategory “Feeling lonely, inadequate, and fragile” reflected experiences of being alone and having no one to share problems and suffering with, and that was said to increase the suffering.

The way participants explained and interpreted their difficulties as related to stressful experiences is supported by research but not fully considered in the DSM-5 system (6, 33,34,35). Furthermore, the current clinical emphases on pharmaceutical symptom reduction and symptom management by e.g., cognitive behavioral psychotherapy do not give much consideration to the importance of previous stressful/traumatic events and how they affect the mental health of young people. With a diagnostic manual that focuses on only symptom criteria, rather than etiology and the subjective experience and understanding of why a person gets depressed, it is unlikely that root causes to the depression will be effectively addressed in treatment.

The Power Threat and Meaning Framework (PTMF) from the British Psychological Society (36) challenges the diagnostic paradigm and highlights existing patterns of systemic power imbalances in the etiology of depressive symptoms. The framework is applicable to the experiences of young individuals with depression, and it provides a method to validate and empower affected individuals (37). The PTMF also emphasizes the subjective narrative and the importance of both individual meaning making and community support for resilience and healing. These are factors that have been shown to impact how patients manage their condition (21,22,23).

It is possible that young people’s own experiences of their depression as related to major life events is not validated enough within the current diagnostic and treatment paradigms. Instead, the cause or even blame for the depression is at times placed on factors within the affected individual him/herself. Understanding young people’s own experience could help build rapport and create a common meeting ground in which the young people’s experiences and understandings are more ealisy validated. This would be in line with the fundamental principles of person-centered care where the personal narrative and building a therapeutic alliance and partnership are highlighted (38). As a result, the patient motivation to participate in treatment could improve, and so could patient empowerment.

In the present study the participants’ reflections on their treatment highlighted a mismatch between what had been offered and what was hoped for and perceived as needed. Described low expectations were often based on negative previous treatment experiences, as described in the subcategory “Being invalidated by professionals”. Participants described being diminished and unseen by health care workers and a lack of follow-up on antidepressant medication. The participants’ views of therapy were similarly negative. Several participants stated that they had already talked to health professionals and others, and nothing had worked so far, and based on that experience the notion arose that nothing would help in the future either. All of this may have been a result of the fact that all participants were interviewed in a non-euthymic state. It is however consistent with previous research indicating that young individuals often have a negative view of psychiatric treatment and that other approaches than standard treatment may be needed (39). We argue that it is important to address the young people’s own experiences and thoughts on the cause of their depression to build trust and improve treatment effects. If young individuals’ own views of their condition are taken into consideration, potential discrepancies with the treatment offered can be acknowledged by clinicians. As a result, treatment alliance may improve and affected individuals may be given opportunities to discuss stressful life events, coping strategies, concerns and expectations. Further action research is needed in which the “users voices” are taken into consideration (40). One attempt to do so was to develop a treatment modality based on young people’s perspective is Training for Awareness Resilience and Action (30, 41), a trauma-informed twelve-week group intervention including emotional self-regulation skills training, empowerment strategies, and a socioecological approach. Future research will reveal if this model can address the issues described above and improve treatment outcomes.

Qualitative methods and semi-structured interviews were used to investigate young people’s understanding of why they got depressed. Purposive sampling was chosen to meet the aim of the study and to strengthen the credibility and provide a varied and informative description (42). The representation of only two county councils in northern Sweden is a limitation, which might affect transferability (42). Including a total of six participants may be considered on the lower side. On the other hand, in qualitative research data is assessed based on its information power (43) and in our case we determined the data to be sufficiently rich and varied to elucidate the aim of the study (42, 43). Also, the interviews were long and the content rich. We do not claim that the results presented are exhaustive. However, the present results are in line with those of previous research synthesis on the causative process (37). In line with trustworthiness in qualitative research, we leave to the reader to decide if the results are transferable to their context. Triangulation between researchers with different competences and perspectives was used to strengthen the study's trustworthiness. More specifically, young and senior researchers (with an age range of 25 – 62), from backgrounds in medicine, nursing, physiotherapy, and pharmacy were involved in the analysis, which led to a mutual illumination of blind spots.

According to our results, relational and contextual factors and life situations are central to the experience of young people’s depression. A combination of overwhelming stressors, lack of support and limited time for recovery was described. The results indicate that mental health care may benefit from elucidating and integrate young people’s individual experiences as has been done in several forms of psychotherapy, that are rarely offered within Child and Adolescent psychiatry of today in Sweden. To validate young individuals with depression and to meet their expectations and needs, new treatment modalities and support structures, including person-centered and trauma informed care, also need to be developed and tested.

Psychiatric diagnoses are descriptive in nature although they are frequently depicted as causal explanations for symptoms (44). Overwhelming life situations appear to be perceived as contributing to symptoms. To actually listen to young people’s narratives and subjective perspectives and to address trauma may therefore be validating for affected individuals and it may also prevent re-traumatization by mental health services. Young people’s understanding of why they got depressed is related to their motivation to participate in treatment and a shared understanding of the problem can improve clinical engagement and outcomes (21,22,23, 45). New approaches that empower and increase resilience to stressful life events are critically needed.