Background
Methods
Design
Protocol and search strategy
Selection: inclusion & exclusion criteria
Data screening and extraction
Quality appraisal
Citation | Sample size | Population studied | Country | Aims | Data collection | Analysis | Themes | Quality Appraisal 1–10 |
---|---|---|---|---|---|---|---|---|
Al-Khattab et al. 2016 [41] | 27 (15 ♂) | Aged 18–21. African-American (AA) adolescents having a) depressive symptoms during adolescence (aged 13–17). 22 participants in total or b) currently aged 13–17 and receiving treatment for depression. 5 participants in total | USA | How AA adolescents describe symptoms of depression through relationships with people in their lives. | Semi-structured interviews | Thematic analysis | 1) keeping others at bay 2) striking out at others 3) seeking help from others 4) joining in with others 5) having others reach out | 7/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design x Appropriate recruitment strategy x Appropriate data collection ✓ Considered reflexivity appropriately Results x Ethical considerations addressed ✓ Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Anttila et al. 2015 [42] | 70 (54 ♂) | Aged 15–17 diagnosed with depression (outpatient) without SMI taking part in RCT for internet-based support system | Finland | Adolescent concerns and hopes when referred to outpatient treatment | Written text/essay before intervention | Thematic analysis | 1) Relationships 2) Daily actions 3) Identity 4) Well-being | 7/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology x Appropriate research design ✓ Appropriate recruitment strategy x Appropriate data collection x Considered reflexivity appropriately Results ✓ Ethical considerations addressed ✓ Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
De Mol et al. 2018 [24] | 15 (9 ♂) | Hospitalized (> 4 months) adolescents (aged 15–18) diagnosed with depression by psychiatrist after receiving outpatient psychotherapy | Belgium | The role of social representations in adolescents’ construction of major depression | Semi-structured interviews | Interpretative Phenomenological Analysis | 1) Depression means personal failure 2) Feeling bad is not allowed and is not normal: in fact, depression doesn’t really exist 3) You are obliged to have an intimate relationship, otherwise you are not normal; 4) It is important to have future projects for personal and social well-being 5) Being socially well integrated is normality. | 10/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design ✓ Appropriate recruitment strategy ✓ Appropriate data collection ✓ Considered reflexivity appropriately Results ✓ Ethical considerations addressed ✓ Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Dundon 2006 [43] (metasynthesis) | 107 (94 ♂) | Aged 13–22. 72 diagnosed or self-reported as depression. 6 studies in total, 2 of which unpublished | USA/ Canada | Contribute to the theoretic base of the experience of adolescent depression, affect future research, and guide clinical practice. | Self-reports, semi-structured interviews | TA, Descriptive, narrative, Participatory action, discourse analysis, grounded research | 1) Beyond the blues 2) Spiraling down and within 3) Breaking points 4) Seeing and being seen 5) Seeking solutions 6) Taking control. | 5/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design x Appropriate recruitment strategy x Appropriate data collection x Considered reflexivity appropriately Results ✓ Ethical considerations addressed x Rigorous data analysis x Clear statement of findings Utility of results ✓ Value of research |
Farmer 2002 [44] | 5 (3 ♂) | 5 adolescents (aged 13–18) diagnosed with depression by therapist. | USA | Experience of major depression from the adolescent’s perspective to provide a more comprehensive description of the disorder. | Semi-structured interviews | Phenomenological approach | 1) Dispirited weariness 2) Emotional homelessness (sense of aloneness) 3) Emotional homelessness (no safety where expected) 4) Unrelenting anger 5) Parental break-up: caught in the middle 6) Spectrum of escape from pain 7) Perspectives on friendship 8) Gaining a sense of getting well | 9/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design ✓ Appropriate recruitment strategy ✓ Appropriate data collection ✓ Considered reflexivity appropriately Results ✓ Ethical considerations addressed x Rigorous data analysis ✓ Clear statement of findings Utility of results X Value of research |
Granek 2006 [45] | 6 (1 ♂) | Students (aged 25–30) gone through an episode of clinical depression (meeting DSM 4 criteria) referring to that period. Didn’t meet criteria for current depression. | Canada | Depressive experience from a subjective perspective | Open ended interviews | Grounded theory/hermeneutic approach | 1) Self in relation 2) Self-criticism and self-loathing 3) Loneliness and disconnection | 6/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design x Appropriate recruitment strategy ✓ Appropriate data collection ✓ Considered reflexivity appropriately Results x Ethical considerations addressed x Rigorous data analysis ✓ Clear statement of findings Utility of results xValue of research |
Kuwabara et al. 2007 [46] | 15 (10 ♂) | Community sample (18–25) currently experiencing depression determined by physician interviewers (severe depression with suicidality was excluded) | USA | Obtain a relatively unconstrained description of the ways in which depression is construed and experienced among a sample of emerging adults. | Semi-structured interviews | Thematic Analysis | 1) Identification as an individual with depression 2) Interactions with the healthcare system 3) Relationships with friends and family 4) Role transitions from childhood to adulthood | 9/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design ✓ Appropriate recruitment strategy ✓ Appropriate data collection ✓ Considered reflexivity appropriately Results x Ethical considerations addressed ✓ Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Lachal et al. 2012 [47] | 5 (3 ♂) | Aged 14–17. Receiving therapy for past depressive episode, 4 participants use medication. Selected after consultation in psychiatry department. Episode was over at the time of interviewing (reflection). | France | How a qualitative method, using in-depth interviews with patients and clinicians, can help building a specific tool to measure depression in adolescents. | Semi-structured interviews | Thematic Analysis | 1) Emotional state 2) Non-emotional manifestations 3) Manifestations in social interactions | 6/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology x Appropriate research design ✓ Appropriate recruitment strategy x Appropriate data collection x Considered reflexivity appropriately Results ✓ Ethical considerations addressed x Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
McCann et al. 2012 [48] | 26 (15 ♂) | Aged 16–25. Purposeful sampling at Headspace via clinicians 1) depression as primary diagnose 2). Excluding psychosis and suicidality. 13 had double diagnose depression + anxiety | Australia | Examine the lived experience of young people diagnosed with depression | Semi-structured interviews | Interpretative Phenomenological Analysis | 1) Struggling to make sense of their situation 2) Spiralling down 3) Withdrawing 4) Contemplating self-harm or suicide | 8/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design x Appropriate recruitment strategy ✓ Appropriate data collection x Considered reflexivity appropriately Results ✓ Ethical considerations addressed ✓ Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Meadus 2007 [49] | 9 (8 ♂) | Aged 15–18 diagnosed with mood disorder (7 depression, 2 bipolar). Treated by psychiatrist or GP. Receiving medication. Both inpatient and outpatient. | Canada | Explore the phenomenon of coping as experienced by adolescents with a mood disorder | Unstructured interviews | Grounded theory, each interview analysed before starting the next interview | 1) Feeling different 2) Cutting off connections 3) Facing the challenge /reconnecting 4) Learning from the experience | 7/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design x Appropriate recruitment strategy ✓ Appropriate data collection x Considered reflexivity appropriately Results ✓ Ethical considerations addressed x Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Midgley et al. 2015 [50] | 77 (55 ♂) | Aged 11–17. Diagnosed with depression with moderate to severe impairment. Part of larger RCT (IMPACT study) clinically referred to child and adolescent mental health services for treatment for depression, but have yet to receive therapy | UK | Exploring the experience of depression in a sample of young people aged between 11 and 17 | Semi-structured interviews (before intervention, rather brief 4-37 min) | Framework analysis | 1) Misery, despair and tears 2) Anger and violence towards self and others 3) A bleak view of everything 4) Isolation and cutting off from the world 5) The impact on education | 9/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design ✓ Appropriate recruitment strategy xAppropriate data collection ✓ Considered reflexivity appropriately Results ✓ Ethical considerations addressed ✓ Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Rosales 2008 [51] (PhD thesis) | 6 (5 ♂) | Aged 12–15 and diagnosed with bipolar disorder, dysthymia, and major depression. Purposeful sampling through community counsellors and school districts professional counsellors, private therapists, school psychologists. Students included were required to have a support system in place such as parents and peers. | USA | middle school adolescents their thoughts and perceptions about their experiences with depression | Semi-structured & open-ended | Comparative method analysis | 1) Person centred 2) Hopelessness 3) Relationships/ connections 4) isolation 5) Escape/ distractions | 7/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design xAppropriate recruitment strategy ✓ Appropriate data collection ✓ Considered reflexivity appropriately Results x Ethical considerations addressed x Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Weitkamp et al. 2016 [52] | 6 (5 ♂) | Aged 14–19. Interviewed after max two sessions with therapist suffering from depressive disorder. Exclusion criteria: cognitively too impaired to participate as rated by therapist/interviewer. All met criteria depression ICD and some with comorbidity of PTSS, anxiety and bereavement. | Germany | Lived experience of young people diagnosed with depression, and additionally to look at the way these YP accessed therapy in the context of the German mental health system. | Semi-structured interviews | Interpretative Phenomenological analysis | 1) Suffering is experienced as overwhelming 2) An experience of loneliness and isolation 3) Struggling to understand the suffering 4) Therapy as a last resort | 8/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design x Appropriate recruitment strategy ✓ Appropriate data collection ✓ Considered reflexivity appropriately Results x Ethical considerations addressed ✓ Rigorous data analysis ✓ Clear statement of findings Utility of results ✓ Value of research |
Woodgate et al. 2006 [53] | 14 (11 ♂) | Aged 13–19. Outpatient diagnosed with depression for > 18 months. 12 other mental health condition as well (e.g. ADHD/substance abuse) but no other severe mental illness. | Canada | Gain an understanding of what it was like to be an adolescent living with depression. | Open-ended interviews & Focus groups (same participants in groups of 6) | Hermeneutic phenomenology | 1) Containing the shadow of fear 2) Keeping the self alive 3) Maintaining a sense of belonging in the world 4) Feeling valued as a human being | 6/10 Validity ✓ Clear aims ✓ Appropriate qualitative methodology ✓ Appropriate research design x Appropriate recruitment strategy ✓ Appropriate data collection x Considered reflexivity appropriately Results ✓ Ethical considerations addressed x Rigorous data analysis x Clear statement of findings Utility of results ✓ Value of research |
Data analysis
External validity
Reflexivity
Results
Description of included studies
Thematic synthesis
Theme 1: social withdrawal due to poor mental health
“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.” (Female in her 10s, USA sample) [43].
“I was in show choir and throughout that year I just didn’t really enjoy it. I was fine with standing in the back, which really wasn’t like me. My wanting to be in the back just wasn’t normal.” [41]
“I become even more withdrawn than I normally am, and it’s based on the insecurity, and it came up the unlikeability thing again, that I’m not likable inherently so what’s the use of pretending that I am because eventually they are going to find out.” (Sarah, teenager; Canadian sample) [45].
People just started drifting away, like they were asking, “What’s wrong with you?” I wanted to ask them, “Why don’t you talk to me anymore?” I felt they were saying “You’re different now!” I just began to hide away a lot and I would say, “I just want to be alone”. (female teenager, USA sample) [51].
Theme 2: non-disclosure of depression and social distance
“I would put on a smile for my parents and my siblings. Whenever somebody would leave and I knew I was going to be alone, they would ask me, “Are you going to be alright?” And I would say “Yes, of course,” because I didn’t want them to know what I was dealing with. But, it was a living hell. I put up a really good façade for them, like all cheery and happy, nothing’s wrong.” (Female in her 20s; USA sample) [41].
Subtheme 2.1 fear of being judged
“I cannot talk about my sadness, in fact, I don’t dare to talk about it, because then you are considered as a weak person. I see that some people feel pity for me, but they don’t talk to me, they prefer to run away because they are afraid and do not know how to react to someone who is sad.” (Female, teenager, Belgian sample) [24].
“If I could talk to them [friends] I would, but I just didn’t feel like I could talk to them. They would keep on going, ‘You’re weird’ or something.” (Sandra, teenager, USA sample) [44].
Subtheme 2.2 preserving friendships
“I’m afraid that friends and significant others can’t see me the same way as before or something might change between us if I told them all my troubles. I don’t want to bother anybody with my worries.” (Unknown gender, 15–17 years old; Finnish sample) [42].
Subtheme 2.3 difficulty explaining oneself
“When you feel bad, you need to have an external explanation for why you have these feelings, because the fact that you feel bad must be caused by something. Participants stated that they often received the question: ‘Why are you feeling so bad?’ Adolescents shared that they cannot give a constructive answer because they do not know why they have these feelings. They could not give explanations because there were no specific causes for them. Due to the inability to provide a real explanation regarding the causes, their feelings and depression are not recognized by others.” [24]
Subtheme 2.4 perceived futility of explaining oneself
“Having others reach out, however, was not always beneficial. Some participants, especially females, did not feel comfortable opening up to those who reached out to them. These participants did not believe the other person would understand what they were going through, believed their problems were ‘no one else’s business’ or doubted the person’s motives for reaching out.”[41]
“Despite the fact that all the individuals in this sample acknowledged social support as an important part of their daily lives, the belief that others cannot understand their experiences often caused individuals to feel alone.” [46]
Theme 3: the desire to connect
“At the same time, the adolescents hoped to have more friends and to be included in their peer group. In addition, they wished to have a good time with the friends and to have somebody to talk to about their problems and feelings.” [42]
“Most individuals have a strong need to connect and have positive relationships with others especially middle school students.” [51]
Shadow clearly had the wish to disclose to someone, which he expressed in a wish for some kind of group therapy to meet people where he could actually speak about his problems: “And maybe, that you can talk about it in a group that you can say: “I am [Shadow], I have this and that problem. What do you think, what is your impression, what is your problem?” . .. Because I can’t possibly walk into my classroom and say: “you know what happened to me?” Well, I could, but. ..” (Male, teenager; German sample) [52].
Theme 4: paradoxes of loneliness and depression
“During their depressive experiences, participants felt a distinct separateness from others and often chose solitude over being with others even when feeling lonely” [44].
“Being around people was, was always a bad thing for me. I constantly felt the need to be alone. .. and I always felt like interacting with other people was difficult for me. .. Ya, that was confusing because I felt lonely but I didn’t feel like being around anyone at the same time” (Jeff, in his 20s, Canadian sample) [45].
Sometimes when some of my friends are … .. ok with ignoring me, with not asking about it, I feel like kind of I know it’s ridiculous, but unloved. (Female, teenager, UK sample) [50].
“They were unable to initiate or sustain relationships because of feelings of severe discomfort around people. They described a cycle of feeling lonely, often as a result of their breakups, and then feeling depressed about the loneliness, causing a self-fulfilling prophecy by further alienating and self-isolating themselves from others.” [45]
“While some disclosed their depression to friends, others withdrew, fearful of the perceived stigma and loss of status from being labelled as having mental illness …. However, retreating from others contributed to their loneliness and isolation.” [48]
“This process of social isolation was characterized by ambivalent feelings. Participants explained that on the one hand they feel the necessity to share their emotions with others, but on the other hand they felt it was impossible to do this. Consequently, they felt caught up in a vicious circle which made them feel alienated from themselves and from of their social world.” [24].