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Adolescent Depression: A Metasynthesis
Original Article
Adolescent Depression: A Metasynthesis Edith ⬙Emma⬙ Dundon, MS, RN, CPNP
ABSTRACT Concerns about the adequate assessment and treatment of adolescent depression have been in the forefront of pediatric mental health literature in the recent past. While quantitative studies have provided valuable information, the voice of the adolescent has been lacking in the development of theory and treatment of this prevalent disorder. Using Noblit and Hare’s 1988 approach, a metasynthesis of six qualitative studies was conducted. This process revealed six themes that outline the course of adolescents who struggle with depression: (a) beyond the blues, (b) spiraling down and within, (c) breaking points, (d) seeing and being seen, (e) seeking solutions, and (f) taking control. Knowledge of the experience of adolescent depression will aid practitioners in recognition and early intervention for the increasing number of adolescents suffering with depression, as well as guide educational initiatives to provide needed information on the symptoms of depression and available resources for getting help. J Pediatr Health Care. (2006) 20, 384-392.
Emma Dundon is a doctoral student at the University of Connecticut School of Nursing, Storrs, Conn. Reprint requests: Emma Dundon, University of Connecticut School of Nursing, 231 Glenbrook Rd, U2026, Storrs, CT 06269-2026; E-mail: [email protected] 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2006.02.010
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Historically, the teenage years have been seen as a stormy time of moodiness, difficult communication, rebelliousness, conflictual relationships, and misunderstanding. This stereotype has the potential to dismiss the symptoms of a group of adolescents for whom this very behavior is a cry for help. Depression in adolescents often is unrecognized by parents, teachers, and most importantly, by medical providers whose job it is to assess and intervene for persons with disturbances in mental health. Concerns about the adequate assessment and treatment of adolescent depression have been in the forefront of pediatric mental health literature in the recent past. Rates of adolescent depression have been estimated between 5% and 15% (Melnyk, Brown, Jones, Kreipe, & Novak, 2003; Olson et al., 2001). Various protocols have been developed in an attempt to aid in prevention and treatment of this disorder (Lewinsohn & Clark, 1999; Mufson et al., 2004; Spense, Sheffield, & Donovan, 2005). While the quantitative studies have provided valuable information, the voice of the adolescent has been lacking in the development of theory and treatment of this prevalent disorder. Only in the past 3 years have there been any qualitative studies aimed at describing and interpreting depression from the view of the adolescent. Metasynthesis is a method of blending a group of qualitative studies in order to discover the common essence in the data and translate that into a new understanding. The aim of this study was to unify the voices of the adolescents who have participated in qualitative research in order to contribute to the theoretic base of the experience of adolescent depression, affect future research, and guide clinical practice. Journal of Pediatric Health Care
TABLE 1. Characteristics of the qualitative studies used in the metasynthesis Author
Year
Place
J. Hetherington, J. Stoppard
2002
Canada
Psychology
T. Farmer
2002
USA
Nursing
“Thematic analysis:” descriptive with semi-structured interview (Strauss & Corbin) Descriptive (Colaizzi)
M. Hinatsu (unpublished)
2002
Canada
Social Work
Narrative therapy
E. Ross, A. Ali, B. Toner
2003
Canada
Unknown; Canadian Journal of Mental Health
Participatory action research
D. Gammel (unpublished)
2003
Canada
Psychology
Discourse analysis
J. Wisdom, C. Green
2004
USA
Public Health and Preventive Medicine
“Modified grounded theory” (Strauss & Corbin)
METHOD Procedure An interdisciplinary online search was done including the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Psyclit, Medline, Sociological Abstracts, and Dissertation Abstracts, from 1970 through January 2005, yielding only six qualitative studies related to adolescent depression. Search terms included adolescent depression, teen depression, child depression, qualitative research, theme, grounded theory, and phenomenology. The only criteria for inclusion in the study were that the design was qualitative in nature and the focus of the study was adolescent depression. Because of the very limited number of studies available, studies were included in which some or all of the participants were not necessarily diagnosed with depression. The inclusion of all available studies in the substantive area of adolescent depression adds to the overall picture of adolescent depression with the inclusion of the voices of those who experiJournal of Pediatric Health Care
Discipline
Method
ence depression in their peer group. Sample The sample of the metasynthesis consisted of six articles published between 2002 and 2004. Of the four published studies, there was one each in the discipline of nursing, psychology, public health, and preventive medicine, and one that did not specify but was published in a mental health journal. Two unpublished dissertations were included, one each from the disciplines of psychology and social work. Table 1 delineates the characteristics of the studies. All studies took place in the United States or Canada. The various research designs used (according to the authors) were one each of participatory action research, modified grounded theory, descriptive, thematic analysis, discourse analysis, and narrative therapy. Because the prevalence of depression is much higher in adolescent girls, by as much as 2:1
Sample
14 girls, ages 14-17 years,none depressed 3 females, 2 males; ages 1317 years; all diagnosed with depression 2 male, 2 female; ages 16-18 years; all diagnosed with depression 48 girls ages 13-22 years in 10 focus groups; 75% history of depression by self-report 14 girls ages 15-20 years; 9 not depressed; 2 diagnosed with depression; 3 self-report of depression Focus group—5 female, 2 male; all age 15 years; interviews—8 female, 7 male, ages 14-19 years; all diagnosed with depression
(Lewinsohn, Rhode, & Seely, 1998), the great majority of participants in the studies were female (94 girls and 13 boys). Out of a total of 107 participants, 72 (67%) were depressed either by diagnosis of a therapist, or by self-report. Data Analysis Noblit and Hare (1988) provided the systematic approach used for conducting this metasynthesis with the following seven steps: a. Getting started by identifying an area of interest. Adolescent depression was chosen as the area of interest that could be informed by a qualitative metasynthesis. b. Deciding what studies are relevant to the area of interest. The researcher made the decision to include all qualitative studies under the substantive area of adolescent depression. c. Reading the studies. The studies were read multiple times to identify the significant data, themes, and concepts. November/December 2006 385
d. Determining how the studies are related. Individual index cards were created indicating all significant pieces of data describing the experience of depression from each study. Groups of cards from each study were then compared to determine their relation to each other. e. Translating the studies into each other. The researcher worked with the data by classifying and then juxtaposing the findings into thematic areas, while retaining the key elements of each study. f. Synthesizing translations. Once the studies were translated into each other, the researcher worked to pull the parts into a new whole which relates a new understanding. g. Expressing the synthesis through writing, drama, art, video, or music. The results of the metasynthesis were documented and reported through a manuscript. These steps are not always consecutive; they have often overlapped and been repeated through the process of creating a new whole. Analyzing and integrating the data from such a wide range of study designs involved certain challenges. Three of the study designs (grounded theory, thematic analysis, and descriptive) yielded data expressed in major themes with details to support them. For the other two designs (narrative therapy and discourse analysis), it was necessary to extract the data through significant statements, then formulate meanings and cluster these findings into themes. The creation of a unified description of the phenomenon by pooling the data from all the studies has led to a unique description that not only exemplifies the experiences of depressed adolescents but also sheds light on the experiences of adolescents who experience depression 386 Volume 20 • Number 6
in their friends, their peers, and their families. RESULTS To juxtapose the findings into a meaningful whole, a table of themes and supporting data from all six studies was created (Table 2). This process revealed six themes that outline the course of adolescents who struggle with depression: (a) beyond the blues, (b) spiraling down and within, (c) breaking points, (d) seeing and being seen, (e) seeking solutions, and (f) taking control. Beyond the Blues Adolescents’ experience of depression encompasses much more than the clinical definition outlined in the American Psychological Association’s (1994) Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Similarities between the DSM IV criteria and the adolescent description are outlined in Table 3. In synthesizing all the data related to descriptions of depression, it was striking to note that there was a continuum of symptoms ranging from very mild to very severe depression with no mutual definition. Teens consider themselves to be depressed whether or not they fit the textbook definition. In addition to the typical symptoms (Table 3), adolescents describe depression as a loss or disconnection from themselves. They talk of being a different person, having a personality change, and losing touch with their real self. They describe being in a fog or a cloud that dulls their perceptions. Describing the case of a 17-yearold boy, Hinatsu (2002) explains, “It was felt that a filter was placed over his eyes and sensory organs. This ‘filter’ was used to screen out all information that ran counter to his depression” (p. 75). Other components of depression described by the adolescents that extend beyond the customary definitions of depression are unre-
lenting anger, powerlessness, feeling abnormal, and feeling the stigma attached to the label. Although irritability is a symptom included in the DSM IV, the anger described by teens appears to be more significant. As these teens in Farmer’s (2002) study express, Sandra: “Like if the slightest thing went wrong, I just wanted to like, hit the person.” Mark: “I hated myself, hated who I was, I hated everything about me. . .I hated them, them being the rest of the world. I pretty much hated them because they hated me.” (Farmer, 2002, p. 576) Anger is directed at parents, siblings, teachers, and objects, with resulting deterioration of relationships, punishments, poor grades, and guilt. The anger could be explosive and unexpected and without significant provocation. The power of depressive symptoms leaves some teens feeling defenseless and lacking control. Depression is described as appearing and taking over during times of vulnerability such as stress or fatigue, and portrayed as something that had to be fought or struggled with. One of Hinatsu’s (2002) participants describes depression as “an enemy or intruder whose sole purpose was to take control of his emotions and life. . .a constant battle that was being waged on a daily basis” (p. 75). Another “viewed her depression to be a ‘big black blob’ that was most likely to get her when she was either ‘stressed out,’ ‘feeling overwhelmed,’ or ‘in a down mood’” (p. 110). The feeling of being different than or abnormal contributes to the adolescent’s discomfort and angst during a depressive episode. As one girl describes, “I think it’s not really accepted to be depressed. . .and if you are then there’s something wrong with you, and I think it occurs quite a bit, but it’s just not brought to the attention of people, of anyone, and then people think, ‘oh, if I was depressed there’s something wrong, I can’t tell anyone beJournal of Pediatric Health Care
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TABLE 2. Individual study metaphors as related to overarching themes
Theme
Hetherington & Stoppard, 2002; Thematic analysis
Beyond the Disconnection from Blues others; loneliness; discomfort with self
Farmer, 2002; descriptive
Hinatsu, 2002; narrative therapy
Ross, Ali & Toner, 2003; participatory action research
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Dispirited weariness; fatigue; Constancy of symptoms; Sadness; change in sleep; emotional emptiness; feeling loss and lost; nothing to live for; absence of affection toward takes away desire to continuum of and from others; live; immobilizing; symptoms; no mutual unworthiness; loss of constant struggle; lose definition connection with self; connection with self; unrelenting anger; fatigue; outside constant, easily triggered controlling force; and explosive deterioration of bottomless pit of relationships, punishments, emptiness; curtain or poor grades, and guilt as a filter over senses; result of anger powerlessness and defenselessness Spiraling Purposeful distancing; Emotional homelessness/ Withdrawal and isolation; Isolation down not belonging; selfsense of aloneness; feeling lost; away from and conscious awareness choosing solitude; feeling friends, family and within different as a cause of school; shame; isolation; decreased selfescape through esteem substances Breaking Arises from troubles Emotional homelessness/no Loss (death, moving); Pressure and stress; family Points with relationships; safety where expected; being different than conflict; strained breaking up results in caught in the middle of others; illness; family relationships; body decreased parental break-ups; changes conflict and chaos; image/media; pressure self-esteem; in relationships; uncertainty in abuse to fit in; difficulty with miscommunication parenting; feeling less loved friends; biological with friends and family; (sibling jealousy) permanent disconnection (death) Seeing and Linked to Friendships: reactions; Parent’s role: either they Confusion; “maybe I’m just being socialization; figuring impulsive acts; (anger) leads see it or they don’t; sad today”; having a seen it out through friends to intervention; dismissal of knowledge leads to safe place to express and family; can’t symptoms by parents delays action; understanding and admit feelings; identify until validated identification; parents gives objective view school counselors and through social recognize symptoms and get family doctors referrals interaction; need for treatment friends/ family to have knowledge in order to identify
Gammel, 2003; discourse analysis
Wisdom & Green, 2004; grounded theory
More than sad; pervasive pessimism; decreased selfesteem; lack of caring; loss of self; feeling abnormal; something is wrong with me; different than; stigma
Being in a funk; depression as compared to sadness; like a fog or cloud, or a weight; pessimism; decreased energy; varies in severity over time; helpless; lost; growth of distress; looking back at happiness; teens are “supposed to be happy”
Loss of interest in activities; isolation; escape
Desire to be alone
Traumatic life events; abuse; relationship conflicts; chemical imbalance; heredity
Triggering events are stress caused by parental divorce, illness, abuse, death; transition to adulthood
Need to identify depression as a reason for concern; lack of awareness leads to persistence; “it’s no big deal”; seeking professional intervention
Considering whether they are depressed; dissonance between now and before; trying to normalize feelings; denial of depression by others and media
Making sense of depression; labelers, medicalizers, identity infusers Normalizing depression; searching for alternate ways of understanding depression; reconnection with others; medication; support groups; negative coping— smoking, substance use/abuse and suicide
Receiving the diagnosis; talking to friends and family first The alternative is suicide; talking to people who know you; knowledge about signs and symptoms leads to getting help
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Phrases in bold are specific themes delineated in the original study.
Gaining a sense of getting well; therapy and support groups; self-care; searching for meaning Coping with depression; importance of not coping alone; gaining insight, new perspectives, and encouragement; suicide as solitary coping Taking control
Reaching out; support groups; finding optimism; challenging depression; regaining control; strength in returning to school, social interactions; reclaiming self
Talk and communication allows for understanding; support from family and friends; hotlines and crisis support; barriers to help are fear, stigma, and stereotypes Activity; improving communication; improving self-esteem; education for parents and teens Talking to friends and professionals; finding someone who really cares Friendship: roles; general support Talking to someone who will listen; talking to someone is the best option; choosing carefully; trust and knowledge important
Farmer, 2002; descriptive Theme
Seeking solutions
Wisdom & Green, 2004; grounded theory Gammel, 2003; discourse analysis Ross, Ali & Toner, 2003; participatory action research Hinatsu, 2002; narrative therapy Hetherington & Stoppard, 2002; Thematic analysis
TABLE 2. Continued
cause then people will think I’m strange or that I’m sick’” (Gammel, 2003, p. 89). Spiraling Down and Within Depression takes adolescents away from friends, family, and school through the impact of its symptoms. Hetherington and Stoppard (2002) use the term “purposeful distancing” to describe the isolation that teens experience. The awareness of being different and the associated striving to appear normal to peers may contribute to this distancing, which is described by participants in each of the studies. Social isolation goes hand-inhand with lack of motivation and decreased energy. Wisdom and Green (2004) described their participants as “being in a funk.” One participant noted: “There would be days that I just couldn’t get out of bed. I didn’t want to face people. I didn’t want to look at anybody, I just wanted to stay there and I guess just sulk by myself, and I just didn’t have any energy” (p. 1232). Some teens feel a sense of responsibility for their depressive symptoms and the effect on academic performance and social relationships. They express feelings of shame and self-criticism when they cannot maintain the level of social activity and academic performance they had prior to the onset of symptoms. As one girl with average capabilities describes, “I’m not dumb enough to be in special ed, so I’m in special ed for an emotional disability. I don’t want to be in special ed” (Farmer, 2002, p. 574). Relationships with friends suffer because the adolescent perceives a need to shield them from the strain of having a depressed friend: “Last year it was really bad, it was probably my worst year last year. . .and I would just like not go out with people, I wouldn’t go anywhere, I’d just stay home because I didn’t want them to like have to deal with it because I know it wasn’t their problem. So, I wanted to like you know, do it Journal of Pediatric Health Care
TABLE 3. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM IV) criteria for depression related to adolescent descriptors of depression DSM IV criteria
Adolescent descriptors
Depressed or irritable mood Diminished interest or pleasure Weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or energy loss Feelings of worthlessness Diminished ability to think or concentrate Recurrent thoughts of death and suicidal ideation
Sadness; “more than sad”; emotional emptiness; overwhelming sadness and despair Lack of caring about self or others; not wanting to do anything
myself” 96 –97).
(Gammel,
2003,
pp.
Breaking Points Throughout the six studies, there are very similar reasons given for the causes of depression in adolescents. The primary causes center around stress related to conflicts in relationships, pressures of
Change in sleeping Decreased energy; fatigue; constantly being weighed down Decreased self-esteem; failure in life Academic downslide; decreased concentration No desire to live; nothing to live for
he just says something and thinks I should think the same way.” “I don’t know how to stress to my mom about how much it hurts when she tells me that I’m a loser, she hates me, I’m a mistake, she wished she never had me. Like, those words are so harsh” (Ross, Ali, & Toner, 2003, p. 59). Pressure to fit into a group, to
Adolescents describe depression as a loss or disconnection from themselves. being an adolescent, loss, and abuse. The most difficult conflicts are with families. Changes in family life due to such factors as parental divorce or separation, death, loss of a sibling, and even going away to college are identified as triggers for depression. Conflicts with parents ranged from distress at not being able to live up to expectations and not feeling seen and heard, to emotional or physical abuse, as these teens describe: “Your parents are really demanding and expect too much from you and you can’t give any more. You can’t make them happy any more. . ..” “When I try to stand up for myself, they say I have an attitude. . .but it’s really just me standing up for what I believe in. [My dad] doesn’t take time to listen to me,
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be in a relationship, to maintain a certain body image, and fitting the image of being a happy, carefree teen weighed heavily in the participants’ descriptions of what caused their depression. The process of transitioning to adulthood created additional stress. For girls especially, the media was faulted for portraying an image that is unattainable. The pressure turns inward, affecting self-image and self-esteem. Moderator: “Where do you think your depression comes from?” Participant A: “From being unhappy with myself and with other people.. . .When I’m sad, I’m sad about certain things, but when I’m depressed I’m upset about myself.” Participant B: “Probably the amount of stress I have in my life and just the pressure I have from
my parents, my school, a lot of my outside environment. I don’t get enough sleep. Usually it’s just a string that starts out with something small and I’ll hold it inside and then I’ll just reach rock bottom where it will just come out” (Wisdom & Green, 2004, p. 1232). Biologic reasons for depression also were mentioned by some of the participants, including the stress of coping with a medical condition and having a chemical imbalance. Additionally, the idea that biology and environment could be connected in causing depression was expressed in Gammel’s (2003) study. “Genetics. . . that’s obvious. . .like just the way you think, the way you process things in your brain. . .everything kind of intermingles to society and genetics” (p. 136). Seeing and Being Seen Although adolescents attempt to distance themselves from their friends and family, those are the very people who help them identify that what they are going through may be depression. Teens expressed confusion in having these symptoms, realizing they are different than their peers, and not knowing why. “I think a lot of girls don’t know. . .the signs of depression. I didn’t know I was depressed until, like, years after. I didn’t know I was depressed and it was clinical depression too. . .I said to myself ‘No!’ Maybe I’m just sad today” (Ross et al., 2003, p. 58). November/December 2006 389
Various routes to identifying depression are described in each study. The first step is a need to identify depression as a reason for concern. The adolescents describe three major pathways in the identification process. The first is recognizing a dissonance within individually and with their peers. They look back in time and recognize a change in their own happiness, or they attempt to normalize their thoughts and actions with those of their peers. “You don’t really like understand what it is or why it’s happening to you or. . .it’s more gradual really. . .. But you might notice it like last year I didn’t feel like this year, why do I?” (Gammel, 2003, p. 104). The second avenue to identification is through observations of
(Hetherington & Stoppard, 2002, p. 623). Some of the participants point out parents and others do not always pick up on symptoms of depression. “A lot of times, it’s dismissed. . .. A lot of times people are like, ‘Oh, she’s 15, she’s depressed, that’s OK, it’ll pass” (Ross et al., 2003, p. 64). Adolescence is often portrayed as a time of emotional upheaval and behavioral change. This normalization of distress blinds the parents to the symptoms their children are exhibiting. The third way that depression is identified in teens is when their actions lead to intervention: “I think almost you have to have another consequence, like there has to be some way it manifests
Other components of depression described by the adolescents. . .are unrelenting anger, powerlessness, feeling abnormal, and feeling the stigma attached to the label. friends and/or family. When friends or family members validate the experience, it allows the teen to accept the possibility of depression. Additionally, hearing about friends’ or family members’ own experiences with depression can open the door to recognition: “I think that maybe if your friends noticed, or if your family noticed and they’re like ‘what’s up with you, like you’re always depressed’ and maybe they’d point it out by continuous situations where its ‘well you’re always sad, you’re always you know pessimistic, you’re always down,’ like ‘I think something’s wrong here.’ I think that if people bring it to their attention then they’d be ‘well, maybe there is,’ like kind of get them thinking about that” 390 Volume 20 • Number 6
itself, like completely dropping out of school or running away or something really drastic like in order for you to recognize it, because if it’s just the depression, they’re [parents] probably going to brush it off as a stage or their personality” (Gammel, 2003, p. 106). When anger leads to impulsive acts with consequences, substance abuse becomes obvious, or there is a suicide attempt or ideation, parents are alerted to the need for intervention and treatment. Seeking Solutions Once the depression is identified, teens believe that talking to someone about the depression is the best action. The adolescents in these studies were in agreement that there were specific criteria to
look for in choosing who to confide in, trustworthiness, and being knowledgeable. The first option most participants suggest is talking to friends or family members, which can help the individual see a new perspective, find encouragement, and gain support for getting more professional help if needed. Disclosure to friends can be difficult, though, given the stigma associated with feelings of depression and the fear of being judged. There are mixed feelings expressed about talking with a professional. On one hand, some of the teens feel that the anonymity a professional provides allows a freedom for self-disclosure. Others believe that it is imperative to approach someone with a closer relationship: “I sincerely don’t believe that it’s helpful to talk. . .to like psychologists or people you don’t know.. . . I think the best people you can get to help you will be people that you know care. . .about you. Not because you’re a person, or because you’re a girl, or because, you know, you’re valuable to society or whatever. . .but because you actually matter to them” (Gammel, 2003, pp. 148 –149). Many of the participants emphasized the role of knowledge in leading to action related to getting help for depression. “What they need to teach in schools is how to recognize when you’re on the verge of a depression, to get yourself some help. . .. So you don’t get to the point where you’re so depressed that you don’t care any more” (Ross et al., 2003, p. 62). Barriers to receiving help also were noted. As mentioned previously, stigma and stereotyping play a strong role in discouraging adolescents from seeking help. Accessibility to care is another significant barrier. Having clinics in the schools can be helpful in this regard, but it also affects privacy issues. Journal of Pediatric Health Care
Taking Control Adolescents appear to have a need to understand or make sense of their depression. Wisdom and Green’s (2004) grounded theory study resulted in a description of three ways that teens reacted to the diagnosis of depression. Labelers were those who believed it was helpful to have a diagnosis, were curious about finding an explanation, viewed the episode as a learning experience, had high selfefficacy, and whose view of time in depression was temporary. Medicalizers were those who responded with some concern and distress to the diagnosis, looked for relief of distress, relied on health professionals, had medium levels of self-efficacy, and whose view of time in depression was
understanding of depression enabled him to challenge his thoughts and feelings. Having an understanding of how his depression worked gave participant A a more objective view of his experience. He described this process as being able to remove the ‘filters’ from his eyes long enough to gain a proper assessment of his situation. Being able to put a ‘pause’ on his depression meant that he could properly judge his emotional reactions. Positive aspects of his life could now be validated and acknowledged” (pp. 84-85). Other positive ways of coping were learning self-care, being active, reaching out, joining support groups, and reclaiming self through the taking the steps of returning to school and social interactions.
Changes in family life due to such factors as parental divorce or separation, death, loss of a sibling, and even going away to college are identified as triggers for depression. long term. Identity infusers saw the diagnosis of depression as a part of their identity. They demonstrated minimal help seeking, were passive participants in treatment, had low self-efficacy, and saw their depression as being permanent. The authors assert that this understanding might help parents and providers tailor therapy for each of the three types of identifications. Participants in Farmer’s (2002) study also searched for meaning in their experiences with depression. They searched for causes but also recognized that “there remained a sense of mystery about why they personally suffered this experience” (p. 580). Hinastu’s (2002) participants found that challenging their depression allowed them to take back control: “Participant A’s Journal of Pediatric Health Care
Negative ways of coping also are illustrated, such as substance use, smoking, or cutting. Suicide is seen as solitary coping, or the most ineffective way of dealing with being depressed. “People who are depressed solve it themselves—it’s suicide” (Hetherington & Stoppard, 2002, p. 626). Again, knowledge and awareness can be instrumental in the process of dealing with depression as this girl points out: “It seems like suicide is one end to depression, the other end being getting help and things like that. . .if you are depressed but you don’t realize it. . .suicide is the answer but if you are depressed and you realize it, it’s like help is the answer, help is the thing. So again awareness could do something with that, because if you’re
depressed and there’s people talking to you about what it is to be depressed, you could recognize the signs and say you know, ‘what can I do, because that’s me’” (Gammel, 2003, p. 166). Discussion related to coping and ideas for prevention overlap in the view of adolescents. Education clearly stands out as the primary issue in preventing depression. The need for teaching about the emotional, physical, and psychological changes associated with adolescence is seen as a method for preventing depression. Additionally, parents and educators are seen as needing education in the recognition and intervention with depressed teens (Ross et al., 2003). For example, one person noted, “I think the most important thing is personal contact, because it might be hard to tell if you are depressed or not. I mean. . .there is an aspect of denial and it’s important for people, I think, who are not depressed to have the information so that they can tell if someone around them is depressed. Because, it’s going to have to be them who helps this person” (Hetherington & Stoppard, 2002, p. 625). Other prevention ideas discussed in the studies are improving self-esteem, improving communication between parents and teens, challenging media’s role in perpetuating unhealthy images, and using media to disseminate information. SUMMARY Through the process of synthesizing the findings of six qualitative studies, a picture has emerged of the experience of adolescents who have depression. Although the defining characteristics are varied, the majority of teens describe a feeling of losing touch with themselves, their friends, and their families. The depression takes over, leaving pessimism, decreased selfesteem, fatigue, anger, and overwhelming sadness in its wake. Casual factors can be attributed to November/December 2006 391
pressure and stress, resulting from the challenges of transitioning from childhood to adulthood, traumatic events and losses, disrupted relationships, and physiologic processes. Taking control of depression requires reaching out for help from trusted and knowledgeable friends or family, or having a safe place to express and admit feelings of dissonance. Once it is identified, finding appropriate outlets for communication of thoughts and feelings, having positive opportunities for improving self-esteem, getting help for negative coping behaviors, and getting help in understanding the meaning of depression are ways that adolescents find their way back to themselves. The voices of the adolescents in these studies are clearly saying that they and their peers need help to be seen. Symptoms of mild to moderate depression need to be identified by parents, educators, and practitioners who are in daily contact with the teens before it develops into a major depressive disorder. When the “typical teenage behavior” of moodiness, anger, isolation, and defiance persist, there is reason to intervene. There is a need for knowledge about depression to be disseminated to children as they are approaching adolescence, as well as to the people around them. Further research is necessary to learn more about adolescents’ experience with depression. This
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metasynthesis begins to represent the experience of depression with adolescents. More needs to be learned, especially from the boys’ point of view, as well as from varied ethnic and socioeconomic populations. The findings from this metasynthesis are limited by the lack of qualitative research to date, the challenges of synthesizing very different types of data, and the fact that not all of the participants had been depressed. Health professionals must be on the forefront in early assessment and intervention for adolescents who may not have the knowledge to know that they can get help, because as Gammel (2003) so aptly relates, “It’s more than just being sad.”
REFERENCES American Psychological Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C: Author. Farmer, T. J. (2002). The experience of major depression: Adolescents’ perspectives. Issues in Mental Health Nursing 23, 567-585. Gammel, D. J. (2003). “It’s more than just being sad”: A qualitative investigation of adolescent girls’ understanding of depression. Unpublished doctoral dissertation, The University of New Brunswick, Canada. Hetherington, J., & Stoppard, J. (2002). The theme of disconnection in adolescent girls’ understanding of depression. Journal of Adolescence 25, 619-629. Hinatsu, M. (2002). A narrative approach to adolescent depression. Unpublished masters thesis. University of Manitoba, Canada.
Lewinsohn, P. M., Rhode, P., & Seely, J. R. (1998). Major depressive disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clinical Psychology Review 18, 765-794. Lewinsohn, P. M., & Clarke, G. N. (1999). Psychosocial treatments for adolescent depression. Clinical Psychology Review 19, 329-342. Melnyk, B. M., Brown, H. E., Jones, D. C., Kreipe, R., & Novak, J. (2003). Improving the mental/psychosocial health of U.S. children and adolescents: Outcomes and implementation strategies from the national KySS summit. Journal of Pediatric Health Care, 17, S1-S24. Mufson, L., Dorta, K., Wickramaratne, P., Nomura, Y., Olfson, M., & Weissman, M. (2004). A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Archives of General Psychiatry, 61, 577-584. Noblit, G. W., & Hare, R. D. (1988). Metaethnography: Synthesizing qualitative studies. Newbury Park, CA: Sage. Olson, A. L., Kelleher, K., Kemper, K. J., Zuckerman, B., Hammond, C. S., & Dietrich, A. J. (2001). Primary care pediatricians’ roles and perceived responsibilities in the identification and management of depression in children and adolescents.Ambulatory Pediatrics, 1, 91-98. Ross, E., Ali, A., & Toner, B. (2003). Investigating issues surrounding depression in adolescent girls across Ontario: A participatory action research project. Canadian Journal of Community Mental Health 22, 55-68. Spense, S., Sheffield, J., & Donovan, C. (2005). Long-term outcome of a school-based universal approach to prevention of depression in adolescents. Journal of Consulting and Clinical Psychology 73, 160-167. Wisdom, J. P., & Green, C. A. (2004). “Being in a funk”: Teens’ efforts to understand their depressive experiences. Qualitative Health Research 14, 1227-1238.
Journal of Pediatric Health Care
Adolescent Depression: A Metasynthesis Edith ⬙Emma⬙ Dundon, MS, RN, CPNP
ABSTRACT Concerns about the adequate assessment and treatment of adolescent depression have been in the forefront of pediatric mental health literature in the recent past. While quantitative studies have provided valuable information, the voice of the adolescent has been lacking in the development of theory and treatment of this prevalent disorder. Using Noblit and Hare’s 1988 approach, a metasynthesis of six qualitative studies was conducted. This process revealed six themes that outline the course of adolescents who struggle with depression: (a) beyond the blues, (b) spiraling down and within, (c) breaking points, (d) seeing and being seen, (e) seeking solutions, and (f) taking control. Knowledge of the experience of adolescent depression will aid practitioners in recognition and early intervention for the increasing number of adolescents suffering with depression, as well as guide educational initiatives to provide needed information on the symptoms of depression and available resources for getting help. J Pediatr Health Care. (2006) 20, 384-392.
Emma Dundon is a doctoral student at the University of Connecticut School of Nursing, Storrs, Conn. Reprint requests: Emma Dundon, University of Connecticut School of Nursing, 231 Glenbrook Rd, U2026, Storrs, CT 06269-2026; E-mail: [email protected] 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2006.02.010
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Historically, the teenage years have been seen as a stormy time of moodiness, difficult communication, rebelliousness, conflictual relationships, and misunderstanding. This stereotype has the potential to dismiss the symptoms of a group of adolescents for whom this very behavior is a cry for help. Depression in adolescents often is unrecognized by parents, teachers, and most importantly, by medical providers whose job it is to assess and intervene for persons with disturbances in mental health. Concerns about the adequate assessment and treatment of adolescent depression have been in the forefront of pediatric mental health literature in the recent past. Rates of adolescent depression have been estimated between 5% and 15% (Melnyk, Brown, Jones, Kreipe, & Novak, 2003; Olson et al., 2001). Various protocols have been developed in an attempt to aid in prevention and treatment of this disorder (Lewinsohn & Clark, 1999; Mufson et al., 2004; Spense, Sheffield, & Donovan, 2005). While the quantitative studies have provided valuable information, the voice of the adolescent has been lacking in the development of theory and treatment of this prevalent disorder. Only in the past 3 years have there been any qualitative studies aimed at describing and interpreting depression from the view of the adolescent. Metasynthesis is a method of blending a group of qualitative studies in order to discover the common essence in the data and translate that into a new understanding. The aim of this study was to unify the voices of the adolescents who have participated in qualitative research in order to contribute to the theoretic base of the experience of adolescent depression, affect future research, and guide clinical practice. Journal of Pediatric Health Care
TABLE 1. Characteristics of the qualitative studies used in the metasynthesis Author
Year
Place
J. Hetherington, J. Stoppard
2002
Canada
Psychology
T. Farmer
2002
USA
Nursing
“Thematic analysis:” descriptive with semi-structured interview (Strauss & Corbin) Descriptive (Colaizzi)
M. Hinatsu (unpublished)
2002
Canada
Social Work
Narrative therapy
E. Ross, A. Ali, B. Toner
2003
Canada
Unknown; Canadian Journal of Mental Health
Participatory action research
D. Gammel (unpublished)
2003
Canada
Psychology
Discourse analysis
J. Wisdom, C. Green
2004
USA
Public Health and Preventive Medicine
“Modified grounded theory” (Strauss & Corbin)
METHOD Procedure An interdisciplinary online search was done including the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Psyclit, Medline, Sociological Abstracts, and Dissertation Abstracts, from 1970 through January 2005, yielding only six qualitative studies related to adolescent depression. Search terms included adolescent depression, teen depression, child depression, qualitative research, theme, grounded theory, and phenomenology. The only criteria for inclusion in the study were that the design was qualitative in nature and the focus of the study was adolescent depression. Because of the very limited number of studies available, studies were included in which some or all of the participants were not necessarily diagnosed with depression. The inclusion of all available studies in the substantive area of adolescent depression adds to the overall picture of adolescent depression with the inclusion of the voices of those who experiJournal of Pediatric Health Care
Discipline
Method
ence depression in their peer group. Sample The sample of the metasynthesis consisted of six articles published between 2002 and 2004. Of the four published studies, there was one each in the discipline of nursing, psychology, public health, and preventive medicine, and one that did not specify but was published in a mental health journal. Two unpublished dissertations were included, one each from the disciplines of psychology and social work. Table 1 delineates the characteristics of the studies. All studies took place in the United States or Canada. The various research designs used (according to the authors) were one each of participatory action research, modified grounded theory, descriptive, thematic analysis, discourse analysis, and narrative therapy. Because the prevalence of depression is much higher in adolescent girls, by as much as 2:1
Sample
14 girls, ages 14-17 years,none depressed 3 females, 2 males; ages 1317 years; all diagnosed with depression 2 male, 2 female; ages 16-18 years; all diagnosed with depression 48 girls ages 13-22 years in 10 focus groups; 75% history of depression by self-report 14 girls ages 15-20 years; 9 not depressed; 2 diagnosed with depression; 3 self-report of depression Focus group—5 female, 2 male; all age 15 years; interviews—8 female, 7 male, ages 14-19 years; all diagnosed with depression
(Lewinsohn, Rhode, & Seely, 1998), the great majority of participants in the studies were female (94 girls and 13 boys). Out of a total of 107 participants, 72 (67%) were depressed either by diagnosis of a therapist, or by self-report. Data Analysis Noblit and Hare (1988) provided the systematic approach used for conducting this metasynthesis with the following seven steps: a. Getting started by identifying an area of interest. Adolescent depression was chosen as the area of interest that could be informed by a qualitative metasynthesis. b. Deciding what studies are relevant to the area of interest. The researcher made the decision to include all qualitative studies under the substantive area of adolescent depression. c. Reading the studies. The studies were read multiple times to identify the significant data, themes, and concepts. November/December 2006 385
d. Determining how the studies are related. Individual index cards were created indicating all significant pieces of data describing the experience of depression from each study. Groups of cards from each study were then compared to determine their relation to each other. e. Translating the studies into each other. The researcher worked with the data by classifying and then juxtaposing the findings into thematic areas, while retaining the key elements of each study. f. Synthesizing translations. Once the studies were translated into each other, the researcher worked to pull the parts into a new whole which relates a new understanding. g. Expressing the synthesis through writing, drama, art, video, or music. The results of the metasynthesis were documented and reported through a manuscript. These steps are not always consecutive; they have often overlapped and been repeated through the process of creating a new whole. Analyzing and integrating the data from such a wide range of study designs involved certain challenges. Three of the study designs (grounded theory, thematic analysis, and descriptive) yielded data expressed in major themes with details to support them. For the other two designs (narrative therapy and discourse analysis), it was necessary to extract the data through significant statements, then formulate meanings and cluster these findings into themes. The creation of a unified description of the phenomenon by pooling the data from all the studies has led to a unique description that not only exemplifies the experiences of depressed adolescents but also sheds light on the experiences of adolescents who experience depression 386 Volume 20 • Number 6
in their friends, their peers, and their families. RESULTS To juxtapose the findings into a meaningful whole, a table of themes and supporting data from all six studies was created (Table 2). This process revealed six themes that outline the course of adolescents who struggle with depression: (a) beyond the blues, (b) spiraling down and within, (c) breaking points, (d) seeing and being seen, (e) seeking solutions, and (f) taking control. Beyond the Blues Adolescents’ experience of depression encompasses much more than the clinical definition outlined in the American Psychological Association’s (1994) Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Similarities between the DSM IV criteria and the adolescent description are outlined in Table 3. In synthesizing all the data related to descriptions of depression, it was striking to note that there was a continuum of symptoms ranging from very mild to very severe depression with no mutual definition. Teens consider themselves to be depressed whether or not they fit the textbook definition. In addition to the typical symptoms (Table 3), adolescents describe depression as a loss or disconnection from themselves. They talk of being a different person, having a personality change, and losing touch with their real self. They describe being in a fog or a cloud that dulls their perceptions. Describing the case of a 17-yearold boy, Hinatsu (2002) explains, “It was felt that a filter was placed over his eyes and sensory organs. This ‘filter’ was used to screen out all information that ran counter to his depression” (p. 75). Other components of depression described by the adolescents that extend beyond the customary definitions of depression are unre-
lenting anger, powerlessness, feeling abnormal, and feeling the stigma attached to the label. Although irritability is a symptom included in the DSM IV, the anger described by teens appears to be more significant. As these teens in Farmer’s (2002) study express, Sandra: “Like if the slightest thing went wrong, I just wanted to like, hit the person.” Mark: “I hated myself, hated who I was, I hated everything about me. . .I hated them, them being the rest of the world. I pretty much hated them because they hated me.” (Farmer, 2002, p. 576) Anger is directed at parents, siblings, teachers, and objects, with resulting deterioration of relationships, punishments, poor grades, and guilt. The anger could be explosive and unexpected and without significant provocation. The power of depressive symptoms leaves some teens feeling defenseless and lacking control. Depression is described as appearing and taking over during times of vulnerability such as stress or fatigue, and portrayed as something that had to be fought or struggled with. One of Hinatsu’s (2002) participants describes depression as “an enemy or intruder whose sole purpose was to take control of his emotions and life. . .a constant battle that was being waged on a daily basis” (p. 75). Another “viewed her depression to be a ‘big black blob’ that was most likely to get her when she was either ‘stressed out,’ ‘feeling overwhelmed,’ or ‘in a down mood’” (p. 110). The feeling of being different than or abnormal contributes to the adolescent’s discomfort and angst during a depressive episode. As one girl describes, “I think it’s not really accepted to be depressed. . .and if you are then there’s something wrong with you, and I think it occurs quite a bit, but it’s just not brought to the attention of people, of anyone, and then people think, ‘oh, if I was depressed there’s something wrong, I can’t tell anyone beJournal of Pediatric Health Care
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TABLE 2. Individual study metaphors as related to overarching themes
Theme
Hetherington & Stoppard, 2002; Thematic analysis
Beyond the Disconnection from Blues others; loneliness; discomfort with self
Farmer, 2002; descriptive
Hinatsu, 2002; narrative therapy
Ross, Ali & Toner, 2003; participatory action research
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Dispirited weariness; fatigue; Constancy of symptoms; Sadness; change in sleep; emotional emptiness; feeling loss and lost; nothing to live for; absence of affection toward takes away desire to continuum of and from others; live; immobilizing; symptoms; no mutual unworthiness; loss of constant struggle; lose definition connection with self; connection with self; unrelenting anger; fatigue; outside constant, easily triggered controlling force; and explosive deterioration of bottomless pit of relationships, punishments, emptiness; curtain or poor grades, and guilt as a filter over senses; result of anger powerlessness and defenselessness Spiraling Purposeful distancing; Emotional homelessness/ Withdrawal and isolation; Isolation down not belonging; selfsense of aloneness; feeling lost; away from and conscious awareness choosing solitude; feeling friends, family and within different as a cause of school; shame; isolation; decreased selfescape through esteem substances Breaking Arises from troubles Emotional homelessness/no Loss (death, moving); Pressure and stress; family Points with relationships; safety where expected; being different than conflict; strained breaking up results in caught in the middle of others; illness; family relationships; body decreased parental break-ups; changes conflict and chaos; image/media; pressure self-esteem; in relationships; uncertainty in abuse to fit in; difficulty with miscommunication parenting; feeling less loved friends; biological with friends and family; (sibling jealousy) permanent disconnection (death) Seeing and Linked to Friendships: reactions; Parent’s role: either they Confusion; “maybe I’m just being socialization; figuring impulsive acts; (anger) leads see it or they don’t; sad today”; having a seen it out through friends to intervention; dismissal of knowledge leads to safe place to express and family; can’t symptoms by parents delays action; understanding and admit feelings; identify until validated identification; parents gives objective view school counselors and through social recognize symptoms and get family doctors referrals interaction; need for treatment friends/ family to have knowledge in order to identify
Gammel, 2003; discourse analysis
Wisdom & Green, 2004; grounded theory
More than sad; pervasive pessimism; decreased selfesteem; lack of caring; loss of self; feeling abnormal; something is wrong with me; different than; stigma
Being in a funk; depression as compared to sadness; like a fog or cloud, or a weight; pessimism; decreased energy; varies in severity over time; helpless; lost; growth of distress; looking back at happiness; teens are “supposed to be happy”
Loss of interest in activities; isolation; escape
Desire to be alone
Traumatic life events; abuse; relationship conflicts; chemical imbalance; heredity
Triggering events are stress caused by parental divorce, illness, abuse, death; transition to adulthood
Need to identify depression as a reason for concern; lack of awareness leads to persistence; “it’s no big deal”; seeking professional intervention
Considering whether they are depressed; dissonance between now and before; trying to normalize feelings; denial of depression by others and media
Making sense of depression; labelers, medicalizers, identity infusers Normalizing depression; searching for alternate ways of understanding depression; reconnection with others; medication; support groups; negative coping— smoking, substance use/abuse and suicide
Receiving the diagnosis; talking to friends and family first The alternative is suicide; talking to people who know you; knowledge about signs and symptoms leads to getting help
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Phrases in bold are specific themes delineated in the original study.
Gaining a sense of getting well; therapy and support groups; self-care; searching for meaning Coping with depression; importance of not coping alone; gaining insight, new perspectives, and encouragement; suicide as solitary coping Taking control
Reaching out; support groups; finding optimism; challenging depression; regaining control; strength in returning to school, social interactions; reclaiming self
Talk and communication allows for understanding; support from family and friends; hotlines and crisis support; barriers to help are fear, stigma, and stereotypes Activity; improving communication; improving self-esteem; education for parents and teens Talking to friends and professionals; finding someone who really cares Friendship: roles; general support Talking to someone who will listen; talking to someone is the best option; choosing carefully; trust and knowledge important
Farmer, 2002; descriptive Theme
Seeking solutions
Wisdom & Green, 2004; grounded theory Gammel, 2003; discourse analysis Ross, Ali & Toner, 2003; participatory action research Hinatsu, 2002; narrative therapy Hetherington & Stoppard, 2002; Thematic analysis
TABLE 2. Continued
cause then people will think I’m strange or that I’m sick’” (Gammel, 2003, p. 89). Spiraling Down and Within Depression takes adolescents away from friends, family, and school through the impact of its symptoms. Hetherington and Stoppard (2002) use the term “purposeful distancing” to describe the isolation that teens experience. The awareness of being different and the associated striving to appear normal to peers may contribute to this distancing, which is described by participants in each of the studies. Social isolation goes hand-inhand with lack of motivation and decreased energy. Wisdom and Green (2004) described their participants as “being in a funk.” One participant noted: “There would be days that I just couldn’t get out of bed. I didn’t want to face people. I didn’t want to look at anybody, I just wanted to stay there and I guess just sulk by myself, and I just didn’t have any energy” (p. 1232). Some teens feel a sense of responsibility for their depressive symptoms and the effect on academic performance and social relationships. They express feelings of shame and self-criticism when they cannot maintain the level of social activity and academic performance they had prior to the onset of symptoms. As one girl with average capabilities describes, “I’m not dumb enough to be in special ed, so I’m in special ed for an emotional disability. I don’t want to be in special ed” (Farmer, 2002, p. 574). Relationships with friends suffer because the adolescent perceives a need to shield them from the strain of having a depressed friend: “Last year it was really bad, it was probably my worst year last year. . .and I would just like not go out with people, I wouldn’t go anywhere, I’d just stay home because I didn’t want them to like have to deal with it because I know it wasn’t their problem. So, I wanted to like you know, do it Journal of Pediatric Health Care
TABLE 3. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM IV) criteria for depression related to adolescent descriptors of depression DSM IV criteria
Adolescent descriptors
Depressed or irritable mood Diminished interest or pleasure Weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or energy loss Feelings of worthlessness Diminished ability to think or concentrate Recurrent thoughts of death and suicidal ideation
Sadness; “more than sad”; emotional emptiness; overwhelming sadness and despair Lack of caring about self or others; not wanting to do anything
myself” 96 –97).
(Gammel,
2003,
pp.
Breaking Points Throughout the six studies, there are very similar reasons given for the causes of depression in adolescents. The primary causes center around stress related to conflicts in relationships, pressures of
Change in sleeping Decreased energy; fatigue; constantly being weighed down Decreased self-esteem; failure in life Academic downslide; decreased concentration No desire to live; nothing to live for
he just says something and thinks I should think the same way.” “I don’t know how to stress to my mom about how much it hurts when she tells me that I’m a loser, she hates me, I’m a mistake, she wished she never had me. Like, those words are so harsh” (Ross, Ali, & Toner, 2003, p. 59). Pressure to fit into a group, to
Adolescents describe depression as a loss or disconnection from themselves. being an adolescent, loss, and abuse. The most difficult conflicts are with families. Changes in family life due to such factors as parental divorce or separation, death, loss of a sibling, and even going away to college are identified as triggers for depression. Conflicts with parents ranged from distress at not being able to live up to expectations and not feeling seen and heard, to emotional or physical abuse, as these teens describe: “Your parents are really demanding and expect too much from you and you can’t give any more. You can’t make them happy any more. . ..” “When I try to stand up for myself, they say I have an attitude. . .but it’s really just me standing up for what I believe in. [My dad] doesn’t take time to listen to me,
Journal of Pediatric Health Care
be in a relationship, to maintain a certain body image, and fitting the image of being a happy, carefree teen weighed heavily in the participants’ descriptions of what caused their depression. The process of transitioning to adulthood created additional stress. For girls especially, the media was faulted for portraying an image that is unattainable. The pressure turns inward, affecting self-image and self-esteem. Moderator: “Where do you think your depression comes from?” Participant A: “From being unhappy with myself and with other people.. . .When I’m sad, I’m sad about certain things, but when I’m depressed I’m upset about myself.” Participant B: “Probably the amount of stress I have in my life and just the pressure I have from
my parents, my school, a lot of my outside environment. I don’t get enough sleep. Usually it’s just a string that starts out with something small and I’ll hold it inside and then I’ll just reach rock bottom where it will just come out” (Wisdom & Green, 2004, p. 1232). Biologic reasons for depression also were mentioned by some of the participants, including the stress of coping with a medical condition and having a chemical imbalance. Additionally, the idea that biology and environment could be connected in causing depression was expressed in Gammel’s (2003) study. “Genetics. . . that’s obvious. . .like just the way you think, the way you process things in your brain. . .everything kind of intermingles to society and genetics” (p. 136). Seeing and Being Seen Although adolescents attempt to distance themselves from their friends and family, those are the very people who help them identify that what they are going through may be depression. Teens expressed confusion in having these symptoms, realizing they are different than their peers, and not knowing why. “I think a lot of girls don’t know. . .the signs of depression. I didn’t know I was depressed until, like, years after. I didn’t know I was depressed and it was clinical depression too. . .I said to myself ‘No!’ Maybe I’m just sad today” (Ross et al., 2003, p. 58). November/December 2006 389
Various routes to identifying depression are described in each study. The first step is a need to identify depression as a reason for concern. The adolescents describe three major pathways in the identification process. The first is recognizing a dissonance within individually and with their peers. They look back in time and recognize a change in their own happiness, or they attempt to normalize their thoughts and actions with those of their peers. “You don’t really like understand what it is or why it’s happening to you or. . .it’s more gradual really. . .. But you might notice it like last year I didn’t feel like this year, why do I?” (Gammel, 2003, p. 104). The second avenue to identification is through observations of
(Hetherington & Stoppard, 2002, p. 623). Some of the participants point out parents and others do not always pick up on symptoms of depression. “A lot of times, it’s dismissed. . .. A lot of times people are like, ‘Oh, she’s 15, she’s depressed, that’s OK, it’ll pass” (Ross et al., 2003, p. 64). Adolescence is often portrayed as a time of emotional upheaval and behavioral change. This normalization of distress blinds the parents to the symptoms their children are exhibiting. The third way that depression is identified in teens is when their actions lead to intervention: “I think almost you have to have another consequence, like there has to be some way it manifests
Other components of depression described by the adolescents. . .are unrelenting anger, powerlessness, feeling abnormal, and feeling the stigma attached to the label. friends and/or family. When friends or family members validate the experience, it allows the teen to accept the possibility of depression. Additionally, hearing about friends’ or family members’ own experiences with depression can open the door to recognition: “I think that maybe if your friends noticed, or if your family noticed and they’re like ‘what’s up with you, like you’re always depressed’ and maybe they’d point it out by continuous situations where its ‘well you’re always sad, you’re always you know pessimistic, you’re always down,’ like ‘I think something’s wrong here.’ I think that if people bring it to their attention then they’d be ‘well, maybe there is,’ like kind of get them thinking about that” 390 Volume 20 • Number 6
itself, like completely dropping out of school or running away or something really drastic like in order for you to recognize it, because if it’s just the depression, they’re [parents] probably going to brush it off as a stage or their personality” (Gammel, 2003, p. 106). When anger leads to impulsive acts with consequences, substance abuse becomes obvious, or there is a suicide attempt or ideation, parents are alerted to the need for intervention and treatment. Seeking Solutions Once the depression is identified, teens believe that talking to someone about the depression is the best action. The adolescents in these studies were in agreement that there were specific criteria to
look for in choosing who to confide in, trustworthiness, and being knowledgeable. The first option most participants suggest is talking to friends or family members, which can help the individual see a new perspective, find encouragement, and gain support for getting more professional help if needed. Disclosure to friends can be difficult, though, given the stigma associated with feelings of depression and the fear of being judged. There are mixed feelings expressed about talking with a professional. On one hand, some of the teens feel that the anonymity a professional provides allows a freedom for self-disclosure. Others believe that it is imperative to approach someone with a closer relationship: “I sincerely don’t believe that it’s helpful to talk. . .to like psychologists or people you don’t know.. . . I think the best people you can get to help you will be people that you know care. . .about you. Not because you’re a person, or because you’re a girl, or because, you know, you’re valuable to society or whatever. . .but because you actually matter to them” (Gammel, 2003, pp. 148 –149). Many of the participants emphasized the role of knowledge in leading to action related to getting help for depression. “What they need to teach in schools is how to recognize when you’re on the verge of a depression, to get yourself some help. . .. So you don’t get to the point where you’re so depressed that you don’t care any more” (Ross et al., 2003, p. 62). Barriers to receiving help also were noted. As mentioned previously, stigma and stereotyping play a strong role in discouraging adolescents from seeking help. Accessibility to care is another significant barrier. Having clinics in the schools can be helpful in this regard, but it also affects privacy issues. Journal of Pediatric Health Care
Taking Control Adolescents appear to have a need to understand or make sense of their depression. Wisdom and Green’s (2004) grounded theory study resulted in a description of three ways that teens reacted to the diagnosis of depression. Labelers were those who believed it was helpful to have a diagnosis, were curious about finding an explanation, viewed the episode as a learning experience, had high selfefficacy, and whose view of time in depression was temporary. Medicalizers were those who responded with some concern and distress to the diagnosis, looked for relief of distress, relied on health professionals, had medium levels of self-efficacy, and whose view of time in depression was
understanding of depression enabled him to challenge his thoughts and feelings. Having an understanding of how his depression worked gave participant A a more objective view of his experience. He described this process as being able to remove the ‘filters’ from his eyes long enough to gain a proper assessment of his situation. Being able to put a ‘pause’ on his depression meant that he could properly judge his emotional reactions. Positive aspects of his life could now be validated and acknowledged” (pp. 84-85). Other positive ways of coping were learning self-care, being active, reaching out, joining support groups, and reclaiming self through the taking the steps of returning to school and social interactions.
Changes in family life due to such factors as parental divorce or separation, death, loss of a sibling, and even going away to college are identified as triggers for depression. long term. Identity infusers saw the diagnosis of depression as a part of their identity. They demonstrated minimal help seeking, were passive participants in treatment, had low self-efficacy, and saw their depression as being permanent. The authors assert that this understanding might help parents and providers tailor therapy for each of the three types of identifications. Participants in Farmer’s (2002) study also searched for meaning in their experiences with depression. They searched for causes but also recognized that “there remained a sense of mystery about why they personally suffered this experience” (p. 580). Hinastu’s (2002) participants found that challenging their depression allowed them to take back control: “Participant A’s Journal of Pediatric Health Care
Negative ways of coping also are illustrated, such as substance use, smoking, or cutting. Suicide is seen as solitary coping, or the most ineffective way of dealing with being depressed. “People who are depressed solve it themselves—it’s suicide” (Hetherington & Stoppard, 2002, p. 626). Again, knowledge and awareness can be instrumental in the process of dealing with depression as this girl points out: “It seems like suicide is one end to depression, the other end being getting help and things like that. . .if you are depressed but you don’t realize it. . .suicide is the answer but if you are depressed and you realize it, it’s like help is the answer, help is the thing. So again awareness could do something with that, because if you’re
depressed and there’s people talking to you about what it is to be depressed, you could recognize the signs and say you know, ‘what can I do, because that’s me’” (Gammel, 2003, p. 166). Discussion related to coping and ideas for prevention overlap in the view of adolescents. Education clearly stands out as the primary issue in preventing depression. The need for teaching about the emotional, physical, and psychological changes associated with adolescence is seen as a method for preventing depression. Additionally, parents and educators are seen as needing education in the recognition and intervention with depressed teens (Ross et al., 2003). For example, one person noted, “I think the most important thing is personal contact, because it might be hard to tell if you are depressed or not. I mean. . .there is an aspect of denial and it’s important for people, I think, who are not depressed to have the information so that they can tell if someone around them is depressed. Because, it’s going to have to be them who helps this person” (Hetherington & Stoppard, 2002, p. 625). Other prevention ideas discussed in the studies are improving self-esteem, improving communication between parents and teens, challenging media’s role in perpetuating unhealthy images, and using media to disseminate information. SUMMARY Through the process of synthesizing the findings of six qualitative studies, a picture has emerged of the experience of adolescents who have depression. Although the defining characteristics are varied, the majority of teens describe a feeling of losing touch with themselves, their friends, and their families. The depression takes over, leaving pessimism, decreased selfesteem, fatigue, anger, and overwhelming sadness in its wake. Casual factors can be attributed to November/December 2006 391
pressure and stress, resulting from the challenges of transitioning from childhood to adulthood, traumatic events and losses, disrupted relationships, and physiologic processes. Taking control of depression requires reaching out for help from trusted and knowledgeable friends or family, or having a safe place to express and admit feelings of dissonance. Once it is identified, finding appropriate outlets for communication of thoughts and feelings, having positive opportunities for improving self-esteem, getting help for negative coping behaviors, and getting help in understanding the meaning of depression are ways that adolescents find their way back to themselves. The voices of the adolescents in these studies are clearly saying that they and their peers need help to be seen. Symptoms of mild to moderate depression need to be identified by parents, educators, and practitioners who are in daily contact with the teens before it develops into a major depressive disorder. When the “typical teenage behavior” of moodiness, anger, isolation, and defiance persist, there is reason to intervene. There is a need for knowledge about depression to be disseminated to children as they are approaching adolescence, as well as to the people around them. Further research is necessary to learn more about adolescents’ experience with depression. This
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metasynthesis begins to represent the experience of depression with adolescents. More needs to be learned, especially from the boys’ point of view, as well as from varied ethnic and socioeconomic populations. The findings from this metasynthesis are limited by the lack of qualitative research to date, the challenges of synthesizing very different types of data, and the fact that not all of the participants had been depressed. Health professionals must be on the forefront in early assessment and intervention for adolescents who may not have the knowledge to know that they can get help, because as Gammel (2003) so aptly relates, “It’s more than just being sad.”
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