A cross-cultural interpersonal model of adolescent depression: A qualitative study in rural Nepal

Intergenerational mental health effects of traumatic victimization in Nepal: A 3-D theory study

BACKGROUND

Intergenerational transmission of trauma is a major focus of international research. Epigenetic, complex-trauma, and intergenerational abuse pattern transmission theoretical explanations all have existing empirical support. Three-D theory argues that in addition to trauma victimization severity, victimization invasiveness and exploitativeness have important independent effects. Moreover, 3-D theory claims that a positive 3-way interaction occurs between trauma victimization invasiveness, exploitativeness, and severity. This study examines the 3-D hypotheses in the context of intergenerational trauma effects on adolescent depression symptoms and suicidal ideation in generation two. Three-D theory may play a particularly important role in intergenerational trauma effects for female victims in the context of conservative South Asian sex role norms.

OBJECTIVE

Test for main effects, two-way, and three-way interaction effects of invasiveness, exploitativeness, and severity of traumatic victimization on intergenerational transmission to adolescent depression and suicidal ideation in generation two. Pathways from maternal depression and borderline personality symptoms as well as physical and sexual abuse and neglect of the adolescent child were also tested.

PARTICIPANTS

and setting. Participants were a nationally representative, random, multi-stage cluster sample of 1089 Nepali mothers and their 15-17 year old adolescent children.

METHODS

Regression models with adjustments for clustering within municipality were used to test the hypotheses.

RESULTS

One in four Nepali adolescents had considered suicide; more than half had high depression scores. A three-way interaction effect between maternal trauma invasiveness, exploitativeness, and severity was positively associated with adolescent depression symptoms. A two-way interaction effect between exploitativeness and severity of maternal trauma was positively associated with adolescent suicidal ideation. Maternal depression, BPD symptoms, and very severe physical abuse of the adolescent were also associated with adolescent depression symptoms.

CONCLUSION

Further research is needed to measure and investigate invasiveness, exploitativeness, and severity of traumatic victimization as they bear on intergenerational transmission of trauma. Examination of intergenerational transmission of self-concept as a potential vector is recommended.

The Power Threat Meaning Framework: a qualitative study of depression in adolescents and young adults

Introduction

Depression constitutes one of our largest global health concerns and current treatment strategies lack convincing evidence of effectiveness in youth. We suggest that this is partly due to inherent limitations of the present diagnostic paradigm that may group fundamentally different conditions together without sufficient consideration of etiology, developmental aspects, or context. Alternatives that complement the diagnostic system are available yet understudied. The Power Threat and Meaning Framework (PTMF) is one option, developed for explanatory and practical purposes. While based on scientific evidence, empirical research on the framework itself is still lacking. This qualitative study was performed to explore the experiences of adolescents and young adults with depression from the perspective of the PTMF.

Methods

We conducted semi-structured interviews with 11 Swedish individuals aged 15- 22 years, mainly female, currently enrolled in a clinical trial for major depressive disorder. Interviews were transcribed verbatim and analyzed with framework analysis informed by the PTMF.

Results

A complex multitude of adversities preceding the onset of depression was described, with a rich variety of effects, interpretations, and reactions. In total, 17 themes were identified in the four dimensions of the PTMF, highlighting the explanatory power of the framework in this context. Not all participants were able to formulate coherent narratives.

Discussion

The PTMF provides a framework for understanding the complexities, common themes, and lived experiences of young individuals with depression. This may be essential for the development of new interventions with increased precision and effectiveness in the young.

The experience of Thai adolescents with depression: A qualitative study

AIM

People who have depression experience a maelstrom of emotion as they attempt to understand what is happening to them. While the experience has been quite extensively documented in adults and older individuals, there is a great deal less information available about adolescent depression experiences and reactions. The purpose of this study was to investigate the experiences of Thai-adolescents suffering from depression.

DESIGN

Interpretative phenomenological analysis.

METHOD

Fourteen adolescents were recruited from a secondary school in Chiangrai province, Thailand. Semi-structured interviews were carried out. Interviews were analysed using interpretative phenomenological analysis.

RESULTS

The following four themes were identified: (1) struggling to make sense of their situation, (2) feeling down and withdrawing, (3) contemplating self-harm and (4) therapy as a last choice. The results point to the continuing significance of promoting psychoeducation for Thai-adolescents with depression as well as parents, school nurses and health providers while eliminating stigma.

Systematic Review and Meta-Synthesis: How Is Depression Experienced by Adolescents? A Synthesis of the Qualitative Literature

OBJECTIVE

To systematically investigate how youth with lived experience report their experience of depression in terms of features of depression and in relation to themselves and their environment.

METHOD

We conducted a systematic review of qualitative research around the world that explored the subjective experience of depression among youth (age range, 10-24 years) who had self-reported, screened positive for, or received a formal diagnosis of the disorder. We used multiple databases to search for relevant studies published in any language up until March 2023. Studies were coded regarding features of depression reported by adolescents. We also used thematic synthesis to extract and synthesize descriptions of the lived experience of depression, and to develop analytic themes. The study was registered with PROSPERO, CRD42021218300.

RESULTS

We identified a total of 23,424 unique records, and included 39 studies in the final review, representing the views of 884 adolescents with lived experience of depression. Most of the studies were conducted in high-income countries (72.8%), and the majority of participants were female (65%). The most frequently reported features of depression were sadness (present in 92.3% of the studies), social withdrawal (76.9%), and loneliness (69.2%). In addition, we constructed 3 themes that aimed to synthesize youths' accounts of their perceptions and experiences of depression: (1) making sense; (2) factoring in culture and contextual influences; and (3) accessing support and care.

CONCLUSION

Some of the more commonly reported features of depression among youth are not explicitly included in the DSM/ICD diagnostic criteria but are highly relevant and closely connected to the experiences of adolescents. Moreover, contextual interpretations of depression may be more sensitive to capture representations and narratives of depression among youth. Thus, incorporating features of depression reported by adolescents could potentially increase accuracy of detection, promote collaborative work, and enhance therapeutic and care outcomes.

STUDY PREREGISTRATION INFORMATION

The lived experience of depression in adolescence: a systematic review of the qualitative literature; https://www.crd.york.ac.uk/prospero/; CRD42021218300.

Coping with depression: a narrative study of an online depression community in China

PURPOSE

The goal of this study was to explore the coping strategies of depression sufferers that have worked for them based on the study of an online depression community.

METHODS

We conducted a thematic narrative analysis of 120 stories posted by the members in the largest online depression community in China. MaxQDA version 18 was used to code the data, and the analytic approach was consistent with the category-centred approach of grounded theory.

RESULTS

The study found that the coping strategies mainly include self-reconciliation (e.g., perceiving/accepting feelings, accepting the present self, and holding hope for the future), actions (recreational activities, physical exercise, and engaging in volunteer work), addressing the stressors and symptoms (e.g., staying away from stressors, seeing the doctor), and seeking interpersonal support (e.g., seeking support from family, friends, and peers).

CONCLUSION

The findings revealed the coping strategies that were helpful and examined how they functioned for the affected members, which make up for the lack of attention to the individual experiences of depression sufferers in coping research. The findings also have practical implications for the related education and consultation, providing useful insights for doctors and patients. These ways of coping are based on depression sufferer' anonymous narratives, which can be convincing to clients.

The Ripple Effect: Unveiling the Bidirectional Relationship Between Negative Life Events and Depressive Symptoms in Medical Cadets

Background

Previous studies have explored the relationship between negative life events and depression, but little is known about the bidirectional relationship between negative life events and depression, particularly in specific groups of medical cadets.

Purpose

This study aimed to explore the relationship between negative life events and depressive symptoms among medical cadets during their four years of college.

Methods

An analysis of 4-wave longitudinal data collected from 2015-2018 was conducted using a cross-lagged panel network (CLPN) model to explore the complex causal relationship between negative life events and depressive symptoms in medical cadets (N=433).

Results

We found differences in negative life events and depressive symptoms among medical cadets across four network models over four years of university. Nodes A-21, A-20, A-23 and A-24, and depressive symptoms D-6 showed greater lagged effect values.

Conclusion

Our findings suggest that there is a lagged and mutually causal interaction between negative life events and depressive symptoms in medical cadets over 4 years of college, but that the predictability of negative life events is more important. However, more attention needs to be paid to the predictive role of depressive symptoms, especially those in early life which are often overlooked. Our study provides new insights into the relationship between negative life events and depressive symptoms in university students and helps to refine strategies for prevention and intervention of depression.

Reciprocal relationship between interpersonal communication and depressive symptoms and the mediating role of resilience across two years: Three-wave cross-lagged panel model

BACKGROUND

Depression among children has been a growing public health concern. It is generally recognized that individuals with depression are likely to have interpersonal malfunctioning. However, there remains a limited scientific understanding of the reciprocal relationship between interpersonal communication and depressive symptoms among rural Chinese children in a longitudinal approach.

METHODS

Therefore, guided by the interpersonal model of depression and the developmental cascade model, the present study conducted a cross-lagged panel analysis study to explore the bidirectional relationship between interpersonal communication and depressive symptoms across three waves among 2188 elementary school students in rural areas of one county of Gansu Province, China. We also examined the mediating effect of resilience and sex differences of the models.

RESULTS

Our results showed that depressive symptoms negatively predicted interpersonal communication from T1 to T2 and T2 to T3. Interpersonal communication negatively predicted depressive symptoms from T1 to T2, but not T2 to T3. Furthermore, resilience showed significant partial mediating effects in the reciprocal relationship between interpersonal communication and depressive symptoms. In terms of sex differences, the significant relationship between depressive symptoms at T1 and interpersonal communication at T2 was found to be significant among male students and marginally significant among female students. The full mediating effect of resilience at T1 was found only among male students, whereas resilience at T2 functioned as a full mediator between depressive symptoms at T2 and interpersonal communication at T3 only among female students.

LIMITATIONS

First, the present sample consisted of only third and fourth grade (i.e., in T1) students from one county in rural China. Second, the present study examined depressive symptoms instead of depression as a clinical diagnosis. Third, the third wave of the data was collected during COVID-19. The impact of the COVID-19 pandemic could unexpectedly pose on child mental health.

CONCLUSIONS

The finding underlined the importance of providing comprehensive depression prevention and intervention from fostering children's inner resilience and promoting their ability to navigate interpersonal resources.

Daily stressors and mental health following disaster: A school-based assessment of adolescent disaster survivors in China and Nepal

Postdisaster daily stressors, the economic and social challenges caused or exacerbated by disasters, have significant consequences for mental health but are rarely investigated in child and adolescent populations. We assessed posttraumatic stress symptoms (PTSS), depression, and anxiety among adolescents affected by disasters in China and Nepal and examined the specific contributions of disaster-related trauma exposure and daily stressors across mental health outcomes. A school-based, cross-sectional study was conducted with a stratified random sampling design. Adolescents living in disaster-affected areas of southern China and Nepal (N = 4,215, 52.7% female, age range: 15-19 years) completed translated, validated measures. Mixed effects logistic regression analyses were conducted using a priori risk factors. PTSS were reported by 22.7% of participants and were higher among Nepali adolescents but did not differ between genders. Depressive symptoms were reported by 45.2% of the sample and were higher among Nepali adolescents and girls in both countries. Across all settings, disaster-related trauma exposure was a significant risk factor for PTSS, depressive, and anxiety symptoms, China: odds ratios (ORs) = 1.44-2.06, Nepal, ORs = 1.21-2.53. High levels of household and interpersonal daily stressors further improved the models and contributed significantly to all mental health difficulties, China: ORs = 1.77-1.98, Nepal: ORs = 1.49-1.90. Postdisaster economic insecurity and interpersonal stressors are thus, likely to worsen adolescent mental health outcomes. Programs that identify and address structural inequalities for adolescents in disaster-affected settings will have cascading effects for mental health.

Community perspectives on the implementation of a group psychological intervention for adolescents with depression: A qualitative study in rural Nepal

Group-based psychological interventions could help to close the treatment gap for depression in low-resource settings, but implementation barriers exist. In Nepal we sought community members' perspectives on how to implement group interpersonal therapy for adolescents. We conducted qualitative interviews with 25 adolescents with depression (aged 13-18) and seven health and non-governmental organization workers, and four focus groups with non-depressed adolescents, four with parents/guardians, and two with teachers (126 participants total). Data were analyzed using the Framework Method. Participants recommended same-sex groups. School was the preferred location because it is accessible for adolescents and acceptable to parents. Adolescents wanted facilitators from their own community with good communication skills. They did not want parents or teachers to participate in groups but emphasized the need to inform parents and obtain their permission. Community members supported group psychological intervention. School-based psychological interventions facilitated by local people could be an acceptable option in rural Nepal.

Measurement invariance of the Multidimensional Depression Assessment Scale (MDAS) across gender and ethnic groups of Asian, Caucasian, Black, and Hispanic

BACKGROUND

Major Depressive Disorder is a severe and highly disabling mental illness. Almost all self-reported questionnaires have overlooked the interpersonal symptoms of depression which are important across gender and culture. The Multidimensional Depression Assessment Scale (MDAS) developed by Cheung and Power (2012) entails comprehensive emotional, cognitive, somatic, and interpersonal subscales. It addresses the criticism that existing self-report depression scales might not cover sufficient phenomenological heterogeneity of depression. The current study aimed to evaluate the psychometric properties of the MDAS across gender and four major ethnic groups of Caucasian, Black, Asian and Hispanic, including reliability and concurrent validity against the Centre for Epidemiological Studies Depression Scale (CESD) and Patients Health Questionnaire (PHQ-9). It also aimed to establish a stable factor structure across gender and ethnic groups and test the measurement invariance to enhance its potential for clinical use.

METHODS

A community sample of 3499 participants from four ethnic groups were recruited via online crowdsourcing sites of Qualtrics and Amazon M Turk. Each individual completed a demographic questionnaire, the MDAS, CESD and PHQ-9.

RESULTS

There was good internal consistency (Cronbach's alpha >0.90) and concurrent reliability across gender and ethnic groups. Strict measurement invariance was established for MDAS over a four-factor factor structure corresponding to the four subscales.

CONCLUSIONS

The MDAS showed good psychometric properties and measurement invariance of a four-factor structure, suggesting its potential to be used in clinical settings across gender and ethnic groups.

LIMITATIONS

Participants all answered the questionnaires in English, which could hinder cultural variations in their expression of symptoms.

Mental health stigma at primary health care centres in Lebanon: qualitative study

BACKGROUND

Mental health-related stigma is a global public health concern and a major barrier to seeking care. In this study, we explored the role of stigma as a barrier to scaling up mental health services in primary health care (PHC) centres in Lebanon. We focused on the experiences of Healthcare Providers (HCPs) providing services to patients with mental health conditions (MHCs), the views of policy makers, and the perceptions of stigma or discrimination among individuals with MHCs. This study was conducted as part of INDIGO-PRIMARY, a larger multinational stigma reduction programme.

METHODS

Semi-structured qualitative interviews (n = 45) were carried out with policy makers (n = 3), PHC management (n = 4), PHC staff (n = 24), and service users (SUs) (n = 14) between August 2018 and September 2019. These interviews explored mental health knowledge, attitudes and behaviour of staff, challenges of providing treatment, and patient outcomes. All interviews were coded using NVivo and a thematic coding framework.

RESULTS

The results of this study are presented under three themes: (1) stigma at PHC level, (2) stigma outside PHC centres, and (3) structural stigma. SUs did not testify to discrimination from HCPs but did describe stigmatising behaviour from their families. Interestingly, at the PHC level, stigma reporting differed among staff according to a power gradient. Nurses and social workers did not explicitly report incidents of stigma but described patients with MHCs as uncooperative, underscoring their internalized negative views on mental health. General practitioners and directors were more outspoken than nurses regarding the challenges faced with mental health patients. Mental health professionals revealed that HCPs still hold implicitly negative views towards patients with MHCs however their attitude has improved recently. Our analysis highlights five layers of stigma affecting SUs.

CONCLUSION

This qualitative study reveals that stigma was still a key concern that affects patients with MHC. SUs reported experiencing overt stigmatising behaviour in the community but less explicit discrimination in a PHC setting. Our findings emphasise the importance of (1) combatting structural stigma through legal reform, (2) addressing interpersonal stigma, (3) committing PHC management to deliver high quality mental health integrated services, and (4) reducing intrapersonal stigma by building public empathy.

School-based group interpersonal therapy for adolescents with depression in rural Nepal: a mixed methods study exploring feasibility, acceptability, and cost

BACKGROUND

Adolescents with depression need access to culturally relevant psychological treatment. In many low- and middle-income countries treatments are only accessible to a minority. We adapted group interpersonal therapy (IPT) for adolescents to be delivered through schools in Nepal. Here we report IPT's feasibility, acceptability, and cost.

METHODS

We recruited 32 boys and 30 girls (aged 13-19) who screened positive for depression. IPT comprised of two individual and 12 group sessions facilitated by nurses or lay workers. Using a pre-post design we assessed adolescents at baseline, post-treatment (0-2 weeks after IPT), and follow-up (8-10 weeks after IPT). We measured depressive symptoms with the Depression Self-Rating Scale (DSRS), and functional impairment with a local tool. To assess intervention fidelity supervisors rated facilitators' IPT skills across 27/90 sessions using a standardised checklist. We conducted qualitative interviews with 16 adolescents and six facilitators post-intervention, and an activity-based cost analysis from the provider perspective.

RESULTS

Adolescents attended 82.3% (standard deviation 18.9) of group sessions. All were followed up. Depression and functional impairment improved between baseline and follow-up: DSRS score decreased by 81% (95% confidence interval 70-95); functional impairment decreased by 288% (249-351). In total, 95.3% of facilitator IPT skills were rated superior/satisfactory. Adolescents found the intervention useful and acceptable, although some had concerns about privacy in schools. The estimate of intervention unit cost was US $96.9 with facilitators operating at capacity.

CONCLUSIONS

School-based group IPT is feasible and acceptable in Nepal. Findings support progression to a randomised controlled trial to assess effectiveness and cost-effectiveness.

Associations between early marriage and preterm delivery: Evidence from lowland Nepal

OBJECTIVES

Preterm delivery (<37 weeks gestation) is the largest cause of child mortality worldwide. Marriage and pregnancy during adolescence have been associated with an increased risk of preterm delivery. We investigate independent associations of age at marriage and age at first pregnancy with preterm delivery in a cohort of women from rural lowland Nepal.

METHODS

We analyzed data from 17 974 women in the Low Birth Weight South Asia Trial. Logistic regression models tested associations of age at marriage and age at first pregnancy with preterm delivery, for primigravida (n = 6 243) and multigravida (n = 11 731) women. Models were adjusted for maternal education, maternal caste, and household asset score.

RESULTS

Ninety percent of participants had married at <18 years and 58% had their first pregnancy at <18 years. 20% of participants delivered preterm. Primigravida participants married at ≤14 years had higher odds of preterm delivery than those married ≥18 years, when adjusting for study design (adjusted odds ratio (aOR) 1.45, 95% CI: 1.15-1.83), confounders (aOR 1.28: 1.01-1.62) and confounders + age at pregnancy (aOR 1.29: 1.00-1.68). Associations were insignificant for multigravida women. No significant associations were observed between age at first pregnancy and preterm delivery.

DISCUSSION

In this population, early marriage, rather than pregnancy, is a risk factor for preterm delivery. We hypothesize that psychological stress, a driver of preterm delivery which is increased among those marrying young, rather than physiological immaturity, drives this association. Further research into the psychological consequences of child marriage in Nepal is needed.

Social isolation as a core feature of adolescent depression: a qualitative study in Porto Alegre, Brazil

PURPOSE

The goal of this study was to explore the perspectives of different stakeholders regarding the experiences of adolescent depression in Porto Alegre, Brazil.

METHODS

We conducted 54 key-informant interviews with adolescents, parents, social workers, health workers, educators, and policy makers and two focus group discussions with 5 adolescents and 6 parents. Data were analysed using a framework approach and guided by the adolescents' personal narratives, with adult stakeholders' views supplementing these perspectives.

RESULTS

Four main themes emerged, creating a relational model of adolescent depression that highlights isolation as a central component of the experience. In relation to the self, the experience of depression led to a feeling of detachment from others resulting from the sensation that usual interactions did not have the same meaning as before. This disruption of interactions is perceived as self-isolation and is described in relation to coping mechanisms.

CONCLUSION

These findings shed light on important aspects of the identification and management of adolescent depression in Brazil. Since social interaction was a core component of the descriptions and experiences of depression, we speculate that promising interventions are those that could enhance the promotion of a supportive environment and interpersonal relationships.