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Lived experiences of adolescents with major depressive disorder during the COVID pandemic: A qualitative study from a tertiary care center
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Received: ,
Accepted: ,
How to cite this article: Jha A, Kiragasur RM, Manohar H, Kommu JV. Lived experiences of adolescents with major depressive disorder during the COVID pandemic: A qualitative study from a tertiary care center. J Neurosci Rural Pract. doi: 10.25259/JNRP_23_2024
Abstract
Objectives:
Depression is a leading cause of global disease burden and morbidity among adolescents. Studies have reported higher rates of depression and anxiety secondary to the COVID pandemic and the psychosocial impact of social distancing measures. There is a paucity of literature on the subjective experiences of depressed adolescents in such pandemic circumstances. The objective of this study was to explore the lived experiences of adolescents with major depressive disorder (MDD) during the COVID pandemic, and the impact of the pandemic, and pandemic-related circumstances on adolescents’ mental health and coping.
Materials and Methods:
In-depth interviews with eight adolescents diagnosed with MDD were analyzed using interpretative phenomenological analysis.
Results:
The analysis revealed three major themes; “The pandemic was arduous,” “Negativity in family interactions,” and “Effects on depression.” Most adolescents coped using excessive screen time as a distraction, and their families perceived them as indolent.
Conclusion:
The study found that adolescents’ experience of depression during the pandemic was extremely overwhelming because, on the one hand, they had to deal with immediate COVID infection-related worries and were not able to adjust to the new routine, not able to concentrate during online classes while also dealing with greater interpersonal discord with their parents and limited social resources for coping. The findings expand the clinical understanding of adolescents’ experience of depression during pandemic circumstances and would aid in better management planning.
Keywords
Adolescent
Depression
Subjective experience
COVID pandemic
Interpretative Phenomenological analyses
INTRODUCTION
The global COVID pandemic impacted almost everyone. The social, economic, and health effects, directly of the pandemic and its associated consequences led to increased mental health issues across all age groups, especially children and adolescents.[1] Children and adolescents faced physical isolation from friends, extended families, and social networks for almost a year due to COVID containment measures such as social distancing and school closure. Studies have shown that the prevalence of significant depressive and anxiety symptoms in children and adolescents during the pandemic doubled compared to pre-pandemic estimates, reaching 25.2% and 20.5%, respectively.[2]
The prevalence of major depressive disorder (MDD) is 8% among adolescents, with higher rates among females. The lifetime and 1-year prevalence is 19% and 8%, respectively.[3] As a result of still developing cognitive and emotional capacities, irritation and anger are important symptoms of MDD in adolescents. In 5–10% of cases, the initial episode of MDD results in chronic recurrent course; in the remaining, partial remissions are more common, with an elevated risk of future recurrences. Post-treatment trial follow-up studies emphasize the importance of continued treatment.[4]
Quite a few studies, predominantly from Western developed countries, have explored adolescents’ experiences with depression, during the non-pandemic times, examining different aspects such as symptoms, perceived causes, family support, and social media use. Twivy et al.[5] reviewed 15 such studies, identifying three main themes (with subthemes): Causes (environmental influences, internal factors, and unclear origins), symptoms (social disconnection, altered sense of self, low mood, negative outlook, anger, overwhelming distress, and fear), and coping (role of others, self-protective strategies, social media as a coping tool, harm to self, and confronting depression). Fewer studies have examined depressed adolescents’ service-seeking experiences.[6]
Three qualitative studies have evaluated COVID’s impact on normal adolescents’ mental health. Montreuil et al.[7] found that online learning, limited social activities, family concerns, and pandemic measures impacted mental health. Hobbies, emotional expressiveness, and resources facilitate coping. Using thematic analysis, Lukoševičiūtė and Šmigelskas[8] found five themes: Ambivalent feelings, changes in daily routine, disappointment with online education, coping strategies, and discoveries. Zaeske et al.[9] explored schooling and mental health experiences using focused group interviews, identifying themes of detachment, disengagement, disappointment, and mental health issues such as adjustment problems, helplessness, hopelessness, and isolation.
Adolescents with MDD often require extended healthcare, making regular treatment for depression a challenging experience.[10] Hormonal changes,[11] emotional,[12] social challenges, academic responsibilities,[13] and managing personal relationships[14] contribute to the complexity of this situation. Pandemic-related containment measures add an additional layer of challenges for effective service utilization, yet there is a notable absence of research on their experiences in such contexts, necessitating attention to this gap. While the pandemic impacted most individuals, it had differentially and intensively impacted individuals with pre-existing mental health conditions compared to those without.[15] As emphasized by the World Health Organization’s guidance on preparing for influenza pandemics like COVID, there is an urgent need to explore depressed adolescents’ lived experiences during the pandemic. Such studies can provide insights into their unique experiences and could inform adaptations in service provision. Therefore, the present study aimed to examine and understand how depressed adolescents perceived their experiences during the COVID pandemic using an interpretative phenomenological analysis (IPA) approach.
MATERIALS AND METHODS
Study design
This was a qualitative study using IPA.
Inclusion/exclusion criteria
Inclusion criteria were as follows: Adolescents presenting to the National Institute of Mental Health and Neuro-Sciences, Department of Child and Adolescent Psychiatry out-patient/in-patient services, and were diagnosed as having MDD by the treating psychiatrist before and during the COVID pandemic as per Diagnostic and Statistical Manual of Mental Disorders-5. Adolescents with a comorbid diagnosis of anxiety spectrum disorder and dissociative disorder were included in the study.
The other inclusion criteria were age between 13 and 18 years, of either gender, fluent in English and who gave written assent and parental consent for the study. Adolescents who had a neurodevelopmental disorder or with comorbid psychotic illness, substance use or acute medical and neurological conditions were excluded from the study. Before starting the study, ethical approval was obtained from the Institute Ethics Committee.
Study participants
Adolescents between 14 and 17 years were recruited from the inpatient and outpatient mental health services of a tertiary care center in South India. Fifteen adolescents with a diagnosis of MDD, with persistent symptoms of depression during the pandemic, along with their parents, were approached for the study. Twelve adolescents who provided assent were recruited, and consent from their parents was obtained.
Study procedure
In-depth interviews were done in adolescent-friendly hospital settings to ensure that they felt at ease. All interviews were conducted in person at the participants’ convenience, lasting between 45 and 60 min on average (around 50 min) in a single session. All interviews were conducted in English and participants willingly shared their experiences, although three adolescents became distressed and tearful when discussing how depression affected them. Prompt attention was given to their distress with an empathetic approach, and the interviews resumed once the participants felt better.
Author (AJ) developed the semi-structured interview after multiple discussions with coauthors. This in-depth interview guide was independently validated by two child mental health professionals (RKM and JVSK). Revisions were made based on the inputs provided by validators and two pilot interviews. The interview schedule covered key aspects such as perception and experience of depression, their perceptions and experiences related to the COVID pandemic, the impact of the pandemic on mental health, and their coping mechanisms. Any emerging aspects mentioned by participants were, further, explored in detail using probes.
Data analysis
The IPA approach was used to analyze the interview transcripts.[16] Interviews with four participants were incomplete, so the final analysis focused on the IDIs of eight adolescents. Each interview’s audio recordings were listened to multiple times, and the transcript was read and re-read to familiarize with the content and understand the participants’ experiences. Initial reading notes included contextual comments, descriptions, and remarks about language and emotions. Interpretive, analytical, and conceptual notes were made during subsequent readings. Emergent themes were formed through meticulous review and analysis of the comments, followed by clustering. The main themes and associated subthemes were identified by analyzing the detailed patterns and connections using the abstraction and subsumption approaches.
RESULTS
Eight participants (four males and four females) aged 14–17, had moderate to severe MDD for 2–3 years with incomplete remission. All had personal experiences with the COVID pandemic and related public health measures. The sociodemographics of the participants is displayed in Table 1, using pseudonyms to protect confidentiality. Most participants came from urban, educated, upper-middle-class backgrounds and had completed or were pursuing higher secondary education. During interviews, most participants received both medications and psychotherapy.
| S. No. | Name (Pseudonym) | Age | Gender | Education | *Socioeconomic status | Background |
|---|---|---|---|---|---|---|
| 1. | Ananya | 15 | Female | 10th Std | Upper middle | Urban |
| 2. | Keshav | 17 | Male | 12th Std | Upper middle | Urban |
| 3. | Niranjani | 16 | Female | 11th Std | Lower middle | Urban |
| 4. | Ravi | 15 | Male | 10th Std | Upper lower | Semi-urban |
| 5. | Rima | 15 | Female | 10th Std | Upper Middle | Urban |
| 6. | Robin | 17 | Male | 12th Std | Upper middle | Urban |
| 7. | Rohita | 14 | female | 9th Std | Upper middle | Urban |
| 8. | Sashwath | 16 | Male | 10th Std | Lower middle | Semi-urban |
The IPA analysis of data revealed three superordinate themes; the pandemic was arduous, negativity in family interactions, and effects on depression.
The pandemic was arduous
This theme comprised five subthemes; “fear of infection,” “irregular routine,” “online classes: Focusing was difficult,” “coping means waned,” and “excess time on screens”.
Fear of infection
Many participants shared experiences of fearing COVID contraction for themselves or loved ones and worrying about the potential outcomes.
Rima: “I would get anxious thinking what if I happen to contract COVID? What will I do? How will I get treated? ...? My father was not there and if something happened to my mother, what would I do? This thought would keep running in my mind.….”
Rima expressed her fears of contracting COVID for herself and her mother, highlighting the added challenge of anxiety symptoms due to being raised by a single parent.
Ananya: “…the graphs of daily deaths made me more and more anxious. I was too scared of going out or letting my family members go out. I would always think something will happen to me or my family members.”
Ananya mentioned that learning about COVID mortality rates heightened her fear of contracting the virus for herself and her family members
Irregular routine
Participants noted that COVID restrictions disrupted their daily routines, making it difficult to adhere to them consistently. This was particularly challenging for adolescents due to their age. Moreover, depressed participants, who spent all the time at home, experienced further complications in establishing and following a routine.
Robin “I used to get up at around 8:30, and then would do some morning rituals ……, sometimes I would not even do…… skipping breakfast and everything. I was not doing anything. I would not talk with anyone, do any household chores. I don’t know how I was spending time…”
Shaswath “…my daily activities got hampered, previously I used to get up at around 6:30 or 6 am. That was also not happening. I was not doing anything other than being in bed and scrolling the phone”
Adolescents emphasized their struggles with waking up on time, initiating routines, neglecting important daily tasks, and facing challenges in doing so due to COVID-related restrictions.
Online classes: Focusing was difficult
Amidst the COVID pandemic, education services transitioned to online learning, presenting a novel and challenging experience. Participants encountered greater difficulties in focusing during virtual classes, struggling to sit in front of a screen. Their attendance was primarily influenced by family members’ insistence.
Ravi: “I always felt offline classes were better than online classes. I cannot pay attention in online classes. I couldn’t sit and keep on listening to someone …., I couldn’t take any notes or ask any questions. I cannot even imagine, how I dealt with all challenges of online classes”
Rohitha; I prefer listening in class and writing my notes…. I think going to school in person is good……. It is too difficult to focus on online classes. You are easily distracted….”
Adolescents recount struggles with concentration during online classes and the difficulty of remaining seated and engaged. Concentration problems, symptomatic of depression, posed heightened challenges for depressed adolescents in the demanding online learning environment.
Social coping got affected
Socialization is crucial for depressed adolescents as it provides emotional support and validation. COVID restrictions limited their interactions with friends and extended family, making it challenging to express themselves. Reduced communication during the pandemic left depressed participants feeling troubled.
Rohitha: “I think going to school in person is good. You get to talk with your friends,………,……you, talk about yourself and family….there are many things that you can only share with your friend. Sharing makes us feel better…
Ananya: I would have enjoyed talking with them [grandparents], interacting with them, sharing my thoughts, but those things were not happening during the lockdown, that’s why I was frustrated.
Unregulated screen-time
Participants spent much of their time on phones or computers engaging in passive activities such as watching movies, playing games, or browsing social media. Limited alternatives during the pandemic led to unregulated screen time as a coping mechanism.
“Rima: Afterward, I didn’t know how I spent most of my time but yes, most of my time would go into watching some movies or watching something, it was only my skin watching and not my soul.”
Rima spent a lot of time watching videos. She metaphorically expressed her inability to enjoy the content, attributing it to depression.
Robin: I was not doing anything… most of the time I was playing games…nothing else I could engage in... Previously, I used to play outdoor games, but then those got completely curtailed.”
Robin spent most of his free time on video games, as outdoor gaming was restricted due to the pandemic. He preferred outdoor gaming for improved physical and mental well-being.
Negativity in family interactions
The superordinate theme encompassed two subthemes concerning the interactional perceptions of depressed adolescents with their parents: “Increased parental instructions” and “negativity in family relations.”
Depression discounted by parents
During COVID restrictions, participants perceived the constant presence of parents and increased parental attention and guidance at home as “intrusive” and “ununderstood,” making it tough for them to deal with. Adolescents felt that their “depression was discounted” and faced rising expectations.
Niranjani: “My parents would frequently come and ask me to do this and that. Even after repeatedly saying to them that I was not in a state to do they would not understand, they would irritate me.”
Robin “They made frequent visits to my room to give advice……. Getting lots of free time with your family member is irritating, you know…it was difficult….”
Parent-adolescent Relationships: From Supportive to Suffocating
Participants’ previously supportive relationships with parents deteriorated due to critical comments as “lazy” and “unhelpful” about their inactivity and requests for daily duties. Parents, dealing with their stress, struggled to understand adolescents’ depression, leading to increasingly critical interactions. Participants acknowledged their parents’ difficult circumstances, but not being helpful made them feel bad.
Rima narrates; “.. she would say to me that I was not helping her,…. our relationship worsened because.…, I felt it was more suffocating…”
Shaswath: “My family members became more critical and complaining. ……. Before they were supportive, but not anymore.……, they felt that I was not helping them”.
Effects on depression
The third superordinate theme of adolescents’ experiences with depression comprises three subthemes: “well aware of symptoms,“ “stress may be the cause,” and “increased suffering.”
Symptoms experience
Participants demonstrated a strong self-awareness of their experiences with depressive symptoms. They used unique metaphors to describe their thoughts, emotions, and physical experiences.
Ravi: the thoughts will keep you chained, keep on repeating in your mind over and over, it’s like infinity.,. You have this dark intense feeling inside you…. it takes away all your abilities.., it brings hollowness in you,…. this invisible illness.…
While discussing the ruminative chain of thoughts, Ravi likened its endless nature to infinity. He further equated feelings of sadness to darkness, highlighting its invisibility to others...
Rima; “…initially, it began with me losing interest…., my mood was intense all the time…, I was not doing what I should do…., I was not knowing how and when things are going to be better ….,
Rima expresses her concerns about recovering and describes her intense mood and loss of interest. She explains how her routine was disrupted, preventing her from accomplishing anything productive as she remained in bed.
Stress might be the cause
Participants felt stress could lead to depression, but could not identify a specific source. They were aware of their depressive symptoms but had limited information about the cause, often attributing it to general stress. This highlights their reasoning abilities and the importance of providing knowledge about the causes of depression.
Sashwath; “…I don’t know exactly, but I think many forms of mental illness are related to stress so I think depression may also be because of increased stress …., maybe it has got something to do with stress…”
Sashwath doubts if all mental illnesses, including depression, stem from excessive stress. His conclusion is based on his understanding of stress and its reduction.
Keshav; “I don’t know how depression is caused….I am the first one that is suffering from this….I think, stress increases it or may cause it, I am not sure...”
Keshav believes that stress can worsen or trigger depression but is uncertain about its causes. He bases this conclusion on hereditary factors and the absence of depression within his family.
Increased suffering
Subjects perceived that the COVID pandemic and its restrictions intensified and prolonged their depressive symptoms. Adapting to online schooling posed new challenges, while prolonged loneliness amplified preoccupation with depressive thoughts. Limited social interactions deprived them of effective coping. The parents’ constant presence and their critical comments added to the stress. Symptoms worsening made the adolescents less functional.
Ananaya; “……, the stressors I had, only increased it dramatically and overburdened me, I was not able to be in contact with any of my friends…, my symptoms had increased over time…, and my family members…. made it worse…”
Robin: My symptoms were not that severe ………. I was able to do some work……. but after this COVID….it added stress……, I was not able to go outside…., My condition worsened”
DISCUSSION
Adolescents with pre-existing depression experienced predominantly negative effects with exacerbation of symptoms due to COVID and its containment measures. Participants feared contracting the virus or infecting their loved ones, although it reduced during the second wave. This finding is consistent with previous quantitative research,[17,18] this fear of infection was associated with emotional reactions[17] and higher levels of depression, anxiety, and insomnia.[19]
Participants struggled significantly with trying to maintain their daily routines, due to COVID-related restrictions. Two qualitative studies among healthy adolescents have reported similar but less intense experiences.[20,21] Maintaining a routine is beneficial for mental health, as it offers predictability amid uncertainty.[22-24] Studies indicated that online classes during COVID were perceived as stressful, demotivating, challenging to adapt to, and difficult to concentrate in.[8,7,17,25,26] This study’s participants faced marked challenges with concentration during online classes, more intense than those reported by depressed adolescents in three studies in traditional schooling settings in non-pandemic circumstances.[27,28] The absence of in-person interactions with peers and extended family members during the pandemic hindered adolescents’ ability to seek support, despite their inclination to share personal concerns is a novel and interesting finding. On the other hand, studies have documented perceptions of in-person interactions being helpful in coping among depressed adolescents in non-pandemic circumstances.[14,27,29] Most participants in the study reported that they relied on prolonged screen time, that included activities such as gaming, watching movies, and surfing social media, as their only means of coping with sadness. Two prior studies have reported comparable results regarding the utilization of social media in non-pandemic periods and gaming during the COVID pandemic as coping mechanisms among depressed adolescents.[5,30] In addition, previous quantitative research has shown a correlation between depression in adolescents and extended gaming time during the COVID pandemic.[31] Furthermore, depression has been found to influence the impact of family conflicts on problematic internet use.[32]
In summary, the study is the first to report that, the depressed adolescent participants, due to COVID and restrictions, feared infection, struggled more with routines compared to healthy adolescents, had significant difficulty focusing in online classes, relied too much on excessive screen time, and felt the loss of social coping mechanisms, exacerbating their situation. All but one of the participants reported constant parental advice or directions, annoying and heightened negative perceptions and conflicts affecting their already negative mood state. Two other studies among healthy adolescents have reported similar perceptions about interactions with parents during COVID.[7,33]
Study participants described their experience of ruminations, fatigue, and lack of motivation using metaphors. Similar descriptions of ruminations,[34] fatigue,[27] and lack of motivation have been reported in other studies involving depressed adolescents. A recent review reported three subthemes in adolescents’ attributions to causes of depression: “environmental influences,” “internal causes,” and “difficulty understanding.”[5] Similar to the third subtheme, the study participants were uncertain about the cause but identified stress as a possible cause. All participants perceived the worsening and prolongation of depression during the pandemic and this study is the first to report this subjective finding. This finding is supported by the conclusions of a cross-sectional quantitative study that found that about 50% of adolescents experienced deterioration of depression due to COVID-related stress and isolation.[15] Overall, our study’s findings align closely with themes identified in studies on the experiences of typical adolescents during the pandemic and depressed adolescents during the non-COVID period. However, our study predominantly revealed heightened and intense negative experiences, attributable to participants’ depression.
CONCLUSION
In pandemics, adolescent depression tends to intensify due to highly disrupting routines, impeding social support-seeking, and impaired focus in online classes. Increased parental presence contributes to negative interactions. Excessive screen time is used as a coping mechanism to distract from distress. This study is the first to report these subjective experiences and these findings have implications for better understanding, management, and prevention of the worsening of depressed adolescents in clinical settings during COVID-like pandemics.
Clinical assessments should consider routines, academic challenges, coping styles, and changes in family relationships and management should incorporate tailored therapeutic interventions to address these aspects.
Teleconsultation should be promptly implemented during pandemics to ensure continuity of care.
Avenues to stay in touch with social circles will decrease stress in adolescents.
Family-focused interventions to ensure a supportive parent-child relationship and address conflicts.
Ethical approval
The research/study approved by the Institutional Review Board at National Institute of Mental Health and Neuro Sciences, Bengaluru, number NIMH/DO/BEH. Sc.Div/2020-21, dated January 2021.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship
Nil.
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