“Adolescents are grumpy, that’s their job description, that’s what they are.” (Collins et al., 2024)
How many times have we heard a similar phrase, either said to ourselves or those around us, at some point in our teenage years? How often have the emotional distress signals given by our friends, family members, or even ourselves been dismissed as just a “phase”, only to find out later it was a part of something much more serious?
One in five children and adolescents globally suffer from symptoms of depression, with these figures rapidly increasing (Lu et al., 2024). Depression remains the most common mental disorder globally (Liu et al., 2020), with a great burden falling on Low and Middle-Income Countries (LMICs). Limited access, stigma, poor screening tools, and insufficient research from these regions to guide policymakers may cause the actual rates to be much higher (see Lucy Barrass’s Mental Elf blog).
The paper under review is a cross-cultural qualitative study by Collins et al that explores the way adolescent depression manifests and is dealt with in Brazil, Nepal, and Nigeria. The authors highlight the role of key social processes, including stigma, involvement of parents, teachers, policymakers, and even technology in influencing whether adolescent depression is appropriately recognised or dismissed in the countries under study.
One in five children and adolescents experience depression.
Methods
The researchers interviewed adolescents to understand their lived experiences of depression (n=153), and held focus groups for parents, teachers, healthcare providers, and policymakers (n=31), from Brazil, Nepal, and Nigeria. Given the cross-cultural nature of qualitative study, the countries were selected on their varying socioeconomic levels to make the research findings relevant.
Participants were adolescents affected by depression and parents of depressed adolescents, recruited using a purposive sampling method. They also included policy makers, health, education and social care workers recruited using convenience sampling. The researchers developed, tested and conducted semi-structured interviews and focus group sessions.
The study used thematic analysis, drawing on existing frameworks; Kleinman’s explanatory model and biopsychosocial model by Engel, while also allowing for new themes to emerge inductively. Thematic codes were developed and validated across multiple coders, focusing on those associated with barriers and facilitators to identifying depression. We can see that authors strengthened their confidence in their findings by accounting for the perspectives of multiple stakeholders, in addition to their chosen analytic framework.
Results
The analysis led to five main themes:
- Lack of awareness of depression, amongst all stakeholders
- The stakeholders role in identification, especially parents and teachers
- Stigma as a barrier
- Mental health training could benefit all stakeholders
- The role of technology as a positive benefit
The research findings highlight how dismantling stigma at each tier of society, in the way that families, schools, and health systems view and understand adolescent emotional distress, is crucial. All participants emphasised that increasing awareness and humanising depressive symptoms experienced by young people is necessary to reduce current stigma.
Recognising the unique ways depressive symptoms may show up in a non-Western context and how that can influence diagnosis was also discussed. Information about mental healthcare available through social media and digital platforms was greatly appreciated, especially in situations where stigma and lack of access can prevent seeking clinical support. These platforms were suggested as a means of improving knowledge of available services and decreasing stigma amongst the community in culturally sensitive ways. However, the negative effect of social media on the self-esteem of depressed young people was also mentioned.
Five main themes were identified including the positives and negatives of technology and social media.
Conclusions
- Tractable barriers: awareness, stigma
- For adolescents, parents, and teachers alike
- Training and public awareness may be a facilitator
- Interventions should be culturally-sensitive
- Potential positive role of digital information
The study under review offers a comprehensive approach by considering the distinct perspectives of all stakeholders involved. However, it also shows that despite parents, teachers, and policymakers being able to recognise and communicate distress, affected adolescents can still fall through the cracks when it comes to access and treatment in timely mental healthcare.
Destigmatisation, building awareness about adolescent depression, training stakeholders to appropriately address these concerns, and positively utilising social media were the key takeaways that could inform future research.
Strengths and limitations
While the “deductive-inductive hybridized” thematic analysis is supported by previous literature, and in itself is a strength (Fereday & Muir-Cochrane, 2006), what stands out is that most researchers had a clinical background, which may have brought a diagnostic lens to the analysis. This could have influenced the interpretation of the participants’ unique sociocultural and emotional experiences, despite an effort to remain as unbiased as possible.
The accounts shared by the adolescent participants are powerful, as most have had experiences with mental health services in the past. Most have also been diagnosed with depression and can recognise the way distress manifests in themselves and their peers.
These perspectives are enriching to the study but also point towards the importance of visibility in research for adolescents coming from families whose first response is not to seek mental health support, but rather to enforce endurance, discipline, and avoidance of the actual distress.
Convenience sampling of some participants and the high female-to-male participant ratio are acknowledged by the authors themselves as a limitation to the study. The sample in all three countries was mostly drawn from urban populations. However, the findings were enriched by including the perspectives of all the stakeholders and not just of the adolescents themselves.
The study acknowledged how the term “depression” may manifest differently, and how mental health training for healthcare providers, community members, and even religious leaders must consider this as well. This shows that mental illness can’t be dealt with in isolation, but needs the entire ecosystem of the affected individuals to fully collaborate.
Implications for practice
This study builds our understanding of the importance of cultural context in global mental health and how it contributes to diagnostic ambiguity. As seen in the sample countries, depression is approached with a different lens as compared to Western-based diagnostic systems. One such example is unique idioms of distress, such as “tension”. As a South-Asian myself, I understand how depression may manifest itself differently, given the context. The added stigma contributes to the severity of distress.
The study highlights the lived experiences of adolescents with depression in mostly urban settings of the included countries; therefore, practitioners should be careful while applying these findings to rural settings. This appears to stem from differing lived experiences, access to mental healthcare, and even the emotional language used to acknowledge symptoms of distress that may vary in adolescents from non-urban settings.
This calls for greater priority in ensuring these voices are included in future research spaces, given the stigma that persists.
In addition to teacher-led identification of distress in schools as suggested, peer-to-peer support approaches may also be helpful. Even from what I have observed in the past, friends are often the first place we share our distress and then gain the confidence to combat societal stigma and seek professional support. This provides opportunities for cross-cultural research in the future to study the effectiveness of such peer support interventions.
This study builds our understanding of the importance of cultural context in global mental health.
University of Glasgow MSc Students
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Statement of interests
Fatima Hayat Malik has none to declare.
Edited by
Simon Bradstreet.
Links
Primary paper
Scott Collins, Katherine Ottman, Jyoti Bohara, Vibha Neupane, Anna Viduani, Silvia Benetti, Thais Martini, Claudia Buchweitz, Olufisayo Momodu, Abiodun Adewuya, Kamal Gautam, Helen Fisher, Christian Kieling, Valeria Mondelli, Brandon Kohrt, Syed Shabab Wahid. (2024) Barriers and facilitators to identifying depression in adolescents: A cross-cultural qualitative study in Brazil, Nepal, and Nigeria. PLOS Ment Health 1(7): e0000209.
Other references
Fereday J, Muir-Cochrane E. Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. International Journal of Qualitative Methods. 2006; 5(1):80–92.
Liu Q., He H., Yang J., Feng X., Zhao F., Lyu J. (2020). Changes in the global burden of depression from 1990 to 2017: Findings from the Global Burden of Disease study. Journal of Psychiatric Research. Volume 126, 134-140.
Lu, B., Lin, L., & Su, X. (2024). Global burden of depression or depressive symptoms in children and adolescents: A systematic review and meta-analysis. Journal of Affective Disorders, 354, 553–562.
