Our final subject population consisted of 10 women and 5 men ranging in age from 18-25 years (mean age 23 years) and reflecting a range of depression severity. CES-D scores ranged from 13 (mild) to 39 (severe). The average CES-D score among participants was 24 (9.29 SD), reflecting a moderately to severely depressed sample. Of the 15 participants, two reported suicidal ideation, while 13 reported having no suicidal thoughts or wishes. In addition, subjects represented a range of ethnicities, socioeconomic backgrounds and social functioning. Seven of the participants were Caucasian, four were African American, and three were Asian. Although the sample ranged in age from 18-25, participants tended to be older and well educated. Four participants indicated that they had some college (2 reported having dropped out due to illness and 2 were currently in school at the time of the interview); five participants indicated they had a college degree; two reported having a graduate level degree and two did not mention their educational status. Participants' family histories were varied. Four of the participants grew up in a single parent home, eight grew up in a two-parent home and the other three did not mention their parents' marital status. In addition, three reported parent or family history of mental illness and three reported parent or family history of substance abuse.
The themes identified in our analysis captured both the individual's experience and their reflected efforts to reconcile symptoms of depression with their previous identities, as well as the themes of navigating treatment, ascertaining their relationships with others, and adjusting to the role transitions inherent in the development from adolescence to adulthood (). describes a hypothesized relationship between these themes. In , depressed mood, identity concerns, adverse relationship interactions and problematic transactions with the health care system adversely impact acquisition of developmental milestones. Similarly, impairment of developmental progress through young adulthood exacerbates concerns about identity and worsens depressed mood.
Interrelationships between themes.
Identification as an individual with depression
With regard to identity, sub-themes included “interruption of identity,” “cultural cues and biological models,” “ambiguity over medical definitions,” and “sadness versus depression.” For many individuals, depressive disorders seemed to both interrupt the development of a sense of identity as a young adult (by making them feel “other than themselves”), and simultaneously became a part of their identities that they mourned or felt they had learned from. While most accepted a biomedical model to explain their depressive disorder, others were concerned that this approach limited alternative frameworks (e.g. psychosocial) that might be helpful to redress their current situation. For example, as one individual said, “It's your balance of chemicals trying to be balanced out” (#002). However, when asked whether she considered depression to be a medical illness another participant said, “… it seems to undercut the possibility that there are much more complicating factors as to why one is feeling depressed than just drugs can solve” (#009). Lack of clarity about the medical definition of the disorder and the boundary between ordinary sadness and depression seemed to make several participants reluctant to fully embrace the perception that they had a disorder which might require clinical treatment. Though few participants mentioned religious experience or coursework in high school or college as an important part of how they understood their experiences with depression, several specifically mentioned advertisements as affecting how they thought about their experiences with depression. Participants did not clearly separate between self-assessment of a possible depressive disorder, their own process of identity development, cultural cues and models, and ideas about what constitutes a reasonable level of ordinary sadness. For example, one participant summarized, “It could be just sadness or it could just be an amalgamation of other sorts of emotions and this is sort of the current cultural construct that we've created to place on top of those feelings. I don't know if depression exists or not really, I just know that I feel really sad” (#007).
Healthcare experiences related to diagnosis and treatment
Several healthcare concerns emerged as topics of concern to study participants, including concerns about access to care (e.g. costs of insurance), a lack of effective treatments, and the stigma of mental illness. Lack of ability to either maintain employment or good standing as student because of depression symptoms often resulted in loss of health insurance. Individuals also lacked families willing and capable of supporting them with either insurance coverage (parent plan) or direct financial assistance for treatment found obtaining mental heath services particularly challenging. Other problems encountered included: long waiting periods, difficulties working with providers, and even problems with transportation. Stigma was both perceived by the depressed individual (“shame”) and from others, in terms of being judged by authority figures and announcing a sense of failure to friends and family. Many participants remained concerned that treatments were not effective or that they could not trust health care providers to care for such critical personal problems. Those who finally turned to community mental health centers or charitable agencies often found waiting lists, transportation challenges, and administrative complexities. Continued concerns about stigma tended to override the motivation and energy need for treatment-seeking endeavors.
Relationships and social support
A central concern seen in the data involved subjects' relationships and methods of social support. Sub-themes included “concerns about meeting parents expectations,” “inability to be understood,” “social withdrawal and isolation,” and “exhaustion of performing normalcy.” Most participants expressed some level of desire not to disappoint their parents with the “failure” of depressive disorders. Several individuals reported that their families were unable to assist or support them because of some combination of conflicts, poverty, or divorce, while others noted the importance of supportive, economically secure parents in facilitating their recovery. 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. Many appeared to react to these concerns by withdrawing or feeling a sense of exhaustion at having to behave as though nothing was wrong. One participant explained, “You just feel so self defeated. It's like you have run a marathon and someone tells you, you have to run another one an you're just like, hands up, like I really can't do this like just physically you can't or mentally or emotionally, you're just drained” (#002). Consequently, many individuals reported that they lacked a peer support system sufficient to provide meaningful assistance.
Role transitions from adolescence into adulthood and general functioning
When asked about the transition from adolescence into adulthood, the emerging adults in our sample spoke of their search for a sense of personal contentment in love, work, and life. Sub-themes included “being overwhelmed with expectations,” “concern about the future,” “feeling time is lost or wasted,” “searching for contentment,” “feeling in-between,” and “optimism.” Many felt their depressive disorder and social circumstances left them barely able to cope with the present and left them overwhelmed in the face of the expectations of emerging adulthood or gaining traction in the quest for a more fruitful future. Several individuals reported a related concern that so much of their time had been “wasted,” leaving them far behind their peers in terms of major life milestones. Other participants reported as much interest in finding current contentment as future direction. Many expressed a feeling of being neither a full adult nor an adolescent. However, many remained optimistic about the future. Individuals in our sample reported on how the clash between current depressed mood, past “failures,” and future expectations could coalesce into profound discouragement, with an adverse impact on their abilities pursue the very goals they sought. One individual described it as, “The collision between anticipation, disappointment and just kind of, if nothing else the seeming unveil lance of the fact that the rest of your life dot, dot, dot, is actually really ambiguous” (#009). Another said, “its like you're falling out of the framework of what you wanted for your life and when you realize you can't have the exact life that you planned, that's such a major thing” (#005).