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Young Women’s Selfhood on Antidepressants: “Not Fully Myself”

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Abstract

The impact of antidepressants on selfhood is well recognized but little is known about what this means for young women who take antidepressants during a key period for identity development. We analyzed interviews with 16 young women to explore the way that antidepressant use might shape selfhood. Thematic analysis was used to identify a range of potential self-related themes in the participants’ narratives including a “diagnosed self,” “an ill self,” “a normal self,” “a stigmatized self,” “an uncertain self,” and a “powerless self.” Themes highlighted the complex influence of antidepressants on young women’s selfhood. Antidepressants not only offered legitimacy for distress and the opportunity to have a more “normal” self but also left the young women challenged by some of the negative associations with antidepressant use and uncertainty about their identity. Prescribers should be mindful of the impact of antidepressants on young women’s developing selfhood.
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Young Women’s Selfhood on Antidepressants: ‘Not Fully Myself’
Celine Wills
University of Auckland, Auckland, New Zealand
Kerry Gibson
University of Auckland, Auckland, New Zealand
Claire Cartwright
University of Auckland, Auckland, New Zealand
John Read
University of East London, London, United Kingdom
Celine Wills, DClinPsy, was a doctoral student in the School of Psychology at the University of
Auckland in Auckland, New Zealand.
Kerry Gibson, PhD, is an associate professor in the School of Psychology at the University of
Auckland in Auckland, New Zealand.
Claire Cartwright PhD, is an associate professor in the School of Psychology at the University of
Auckland in Auckland, New Zealand
John Read, PhD, is a professor in the School of Psychology at the University of East London in
London, United Kingdom.
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Abstract
The impact of antidepressants on selfhood is well recognized but little is known about what
this means for young women who take antidepressants during a key period for identity
development. We analyzed interviews with 16 young women to explore the way that
antidepressant use might shape selfhood. Thematic analysis was used to identify a range of
potential self-related themes in the participants’ narratives including a ‘diagnosed self’, ‘an ill
self’, ‘a normal self’, ‘a stigmatized self’, ‘an uncertain self’ and a ‘powerless self’. Themes
highlighted the complex influence of antidepressants on young women’s selfhood.
Antidepressants offered legitimacy for distress and the opportunity to have a more ‘normal’
self, but also left the young women challenged by some of the negative associations with
antidepressant use and uncertainty about their identity. Prescribers should be mindful of the
impact of antidepressants on young women’s developing selfhood.
Keywords
Depression; medication; self; young women
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Introduction
Antidepressant use has increased significantly over the last several decades in many
developed countries including New Zealand, where prescribing is reported to have increased
21% between 2008 and 2015 (Wilkinson & Mulder, 2018). Women make up the majority of
those who use this medication, with 16% of New Zealand women prescribed antidepressants
in 2015. Antidepressant prescriptions for young people have also risen significantly
(Bachmann et al., 2016), and the growing number of young women being diagnosed with
depression suggests that they might be a significant target for antidepressant prescribing
(Mojtabai, Olfson & Han, 2016).
While antidepressant use is on the rise, the value of treating depression with
antidepressants has been the subject of considerable debate in the research literature
(Fountoulakis & Möller, 2011; Kirsch et al., 2008). In particular, concerns have been raised
about whether the risks outweigh the benefits for young people (Coon et al., 2017). Besides
the direct impact of these medications on depressive symptoms, antidepressants also have
profound consequences for a sense of self as they are designed specifically to alter people’s
emotional experience of themselves and the world (Karp, 2006). With a growing number of
young women taking antidepressants, it is vital to understand the consequences of this at a key
point in their development of identity.
Youth, Selfhood and Antidepressants
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Youth has long been viewed as an important period for the development of identity.
Traditional theorists conceptualized this as an internally driven developmental stage focused
on the making of a coherent identity. Erikson (1968), for example, situated ‘identity versus
role confusion’ as the predominant conflict between the ages of 12 and 19 although he did not
see identity seeking as a finite process which was resolved during this period. In more recent
years, youth researchers have challenged the idea of an absolute demarcation of adolescence
and adulthood, recognizing instead that in contemporary societies there is an extension of
some aspects of adolescence up to the mid-twenties, sometimes called ‘emerging adulthood’
(Tanner & Arnett, 2009). In this period, identity issues remain paramount for young people.
While developmental theories still provide a framework for some researchers
interested in youth identity, others have drawn from narrative theory to conceptualize identity
as a more fluid product of the stories that people tell about their lives (McAdams, 1985). In
this article we use the concept of selfhood to describe the way that individuals make sense of
their own identities through narratives (McAdams, 1985). From this perspective, people are
seen as active in constructing their own identities through the stories they tell about
themselves. At the same time, it is recognized that these stories are shaped (as well as
constrained) by the cultural resources available to them (McAdams, 2011). These cultural
resources are multiple and contradictory allowing for a range of different identity
constructions that may be more or less salient for different individuals and social groups at
different times (Bamberg, De Fina & Schiffrin, 2011). These narrative identities have
consequences for the way that people live and experience their lives.
Young people’s narratives of selfhood are shaped by contemporary cultural
representations of youth and the contexts in which these are constructed (White & Wyn,
2013). Some of these influences include the pressure to develop an individually negotiated
and self-actualized identity in spite of social conditions that make this difficult (Illouz, 2008).
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This is likely to be particularly challenging for women who experience a range of social
adversities thought to explain their higher rates of depression (Nolen-Hoeksema, 2001;
Ussher, 2010). What counts as self-actualization is also gendered. McRobbie (2008), for
example, has argued that there is particular pressure on young women in a post- feminist era
to live up to expectations that they should be successful and in control of their lives.
Young women are also developing selfhood in a time in which mental health
problems are increasingly ascribed to a biochemical vulnerability. Rose (2003) uses the
concept of ‘neurochemical selves’ to describe the way that, in recent times, understandings
of distress have become inextricably linked to biology and argues that this helps to establish a
boundary between what is considered normal and abnormal in society. Dominant discourses
represent depression as a biochemical disease with references to this in online health
information about depression and in advertisements for antidepressants (Metzl & Angel,
2004). Karp (1993) describes how taking antidepressants reinforces a biochemical
understanding of selfhood. As he puts it: “putting the first pill into one’s mouth begins both a
revision of one’s biochemistry and one’s self” (p. 346).
Lafrance (2007) investigated women’s experiences of using antidepressants and noted
that participants in her study welcomed a prescription of the medication as it legitimized their
distress as a medical problem. She argued, however, that this interpretation ultimately
provided ‘cold comfort’ to the women, delegitimizing the real sources of their distress the
social world (p. 135). The bio-medicalization of distress is a salient issue for women whose
emotion is often reduced to biology (Ussher, 2010). Young women’s distress, in particular, is
often dismissed as ‘emotional volatility’ associated with the biological changes of puberty
(Sparks, 2002). This minimizes the unique demands on teenage girls, who are learning to
navigate a social environment that requires much of young women while simultaneously being
stressful and devaluing (Wiklund et al., 2014). Defining young women’s distress as an illness
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and treating it with medication has the potential to undermine the significance of their distress
as a reasonable response to the challenges they face in society. On the other hand, Fullagar
(2009), who provided a critical analysis of women’s experiences with antidepressants, noted
that the medication also conjures up the compelling possibility of restoring ‘normality’ for
women who cannot live up to what society expects of them.
In addition, taking antidepressants has important consequences for people’s sense of
agency and control over their lives. Fullagar (2009) argued that taking antidepressants in order
to feel better might render women’s own efforts to improve their lives invisible. The authors
have, in another article, described a process in which antidepressant use gave women a sense
of agency in dealing with their distress, but also noted how the biochemical model and longer
term use of antidepressants undermined this agency (Cartwright, Gibson & Read, 2018)
Researchers have highlighted other complex ways in which antidepressants can affect
people’s selfhood. A range of studies have suggested that while people who used
antidepressants felt that the medication helped with their symptoms, this often came at the cost
of experiencing themselves as damaged or wounded (Metzl & Angel, 2004). Garfield, Smith
and Francis (2003) captured the paradoxical way that while antidepressants made some people
feel better, this came with a sense inadequacy that they were needed in the first place. As they
put it, this left the antidepressant user “returning to normal functioning while losing the sense
of being normal” (p. 521). But while there is a substantial body of research on adults using
antidepressants, there is less which explores how these issues might play out in relation to
young people’s developing sense of self. One of the few available studies on young women’s
experiences with antidepressants draws from interviews with 12 participants. This research
suggests that young women might face a similar conflict between feeling better on
antidepressants and struggling with the negative connotations of an illness identity (Knudsen,
Hansen & Traulsen, 2002; Knudsen, Hansen, Traulsen & Eskildsen, 2002; Knudsen, Hansen
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& Eskildsen, 2003). Knudsen, Hansen and Traulsen (2002) also highlight the impact of the
stigma associated with using antidepressants, using the phrase “double stigma” to capture the
experience of treating a stigmatizing problem (i.e. depression) with a stigmatized medication.
While the existing research indicates that antidepressant use might have significant
effects on young women’s developing sense of self there has been surprisingly little attention
paid to the significance of selfhood as a developmental issue for this age group. The current
research aims to contribute to the limited body of knowledge about young women’s
experiences of using antidepressants and to explore the significance of this for their developing
selfhood. In this article we address the question: ‘How do antidepressants shape selfhood in
young women?’
Methodology
Our methodology draws from a narrative approach which is based on the idea that we
all naturally story our experiences in order to make sense of our experience (Gergen, 1998). A
narrative approach recognises that people tell their own stories of their lives but that these are
constrained by the cultural resources available in a particular time and place. Narratives thus
allow the possibility of seeing both individual meaning making and the influence of society on
this (Clandinin & Connelly, 2000). While narratives provide a way for people to organise their
experiences and create meaning, storytelling is also the way people produce and communicate
their sense of self. In telling a story, a person connects events across time, which in turn, creates
a coherent sense of self, with a past, present and future (Elliot, 2005). In doing this, individuals
draw upon the available models of identity and self in society at large and the culturally
sanctioned plotlines or “scripts” that go along with these, in order to construct their sense of
self (Gergen, 1998). From this perspective, identity emerges as a product of the narrative itself.
In this study we asked young women to tell us their story of using antidepressants in
their own words. While identity was not the only focus of our attention, the methodology lent
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itself to an exploration of selfhood. Our initial readings of the data confirmed this as an
important area in which to focus our analysis.
This perspective requires that we adopt a reflexive position on our own roles in this
research (Ezzy, 2002). As mental health professionals, the researchers were in close contact
with the dominant discourses around the value of antidepressants in treating depression, but we
were also privy to other stories in private or therapeutic settings where we heard about the
struggles people experienced with this medication. Celine Wills who conducted these
interviews is also a young woman who was attuned to some of the challenges associated with
this period of life.
The research was approved by the University of Auckland Human Participants Ethics
Committee and all participants provided written informed consent to take part in the study.
Participants
Participants were recruited from a large pool of people that took part in an online survey
on antidepressant use which was widely advertised through the media in New Zealand (Read,
Cartwright & Gibson, 2014). Having completed the survey, potential participants registered
their interest in taking part in a follow-up interview study. Sixteen participants aged between
18 and 25 years who had taken antidepressants for six months or more were included in this
study. Thirteen participants identified as New Zealand/European, while one identified as New
Zealand/European and South African, one as Chinese and one as Tongan/ Filipino. Eight of the
participants were students while the remaining participants were employed (in occupations that
included counsellor, nurse, teacher, youth worker, fundraiser, café worker and office manager).
Seven participants were taking antidepressants at the time of the interview, while the other
eight participants had stopped taking them between six months- two years earlier. The length
of time that participants had taken this medication ranged from 6 months to 8 years, and the
average length of time was 3 years and 4 months. Seven participants had started taking
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antidepressants during their teenage years and the majority of others in their very early
twenties. We did not require participants to have had a formal diagnosis, but most identified
with a label of depression although a small number also recognized anxiety as a part of their
difficulties.
Data Gathering
All interviews were conducted by Celine Wills at a time and place convenient to the
participant. Interviews lasted between three quarters of an hour and two and half hours. The
interviews were digitally recorded and transcribed verbatim.
The interviews were conducted in a narrative style designed to prioritize the
participants’ own accounts of their experiences with antidepressants (Riessman, 2008). The
interviews began with the researcher asking participants to tell their story of how they began
taking antidepressants. This usually elicited a response that lasted between 10-20 minutes,
where the researcher’s responses were limited to non-verbal signals of attentive listening. Once
the participant’s story had been elicited, the researcher asked the interviewee to go back to parts
of their story in order to gain more information. Questions were generally open-ended and
designed to encourage spontaneous descriptions of the participants’ own understandings the
significance of the medication in their lives (Riessman, 2008). Given the depth and richness of
the interviews, the sample size was considered sufficient for this analysis (Malterud, Siersma
& Guassora, 2016).
Understandably, talking about their experiences of taking antidepressants was an
emotional experience for many participants. Some became tearful at different points during the
interview. The researcher aimed to listen attentively, be validating and empathetic, and let the
interviewees know that they could take a break should they need to. Despite this, all
interviewees chose to complete their interview. The researcher checked with each of them at
the end of the interview how they were feeling, and offered a list of resources for support.
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Data Analysis
Transcripts were analyzed using thematic analysis, which involves coding content
around common themes (Braun and Clarke, 2006; Braun & Clarke, 2012). In the analysis
described in this article we focused specifically on the way that the participants represented
their selfhood in relation to antidepressant use. Initially, the printed transcripts were read and
re-read in order to gain an overall understanding and familiarity of the text, and to begin
noticing patterns throughout the text. After this, transcripts were then analyzed line by line, and
initial codes were generated. After coding all the data, we identified all codes that related to
selfhood and began a process of generating themes which related to the research question. All
themes were then reviewed based on relevance to and inclusiveness of data, which involved
combining some themes, and discarding others. Data within each theme were discussed
between the researchers to ensure appropriate fit and sufficient data inclusion. Once themes
and subthemes had been established, one of the final stages was naming these themes, and
defining them more clearly. This meant organizing the data in a coherent manner, analyzing
and writing a detailed account of each theme.
Trustworthiness was improved in the present study by documenting each step of the
research process in detail, including research design, methods, analysis and conclusions, so that
it could be open to scrutiny (Riessman, 1993). Reflexivity was fostered through on-going
dialogue between the researchers about each transcript and its significance as well as the
themes as these were developed. This also means that there is a high degree of transparency
and that researchers could repeat this work, even if they do not necessarily get the same results
(Shenton, 2004). Dependability was improved in the present study through peer review. This
was achieved through co-researchers and colleagues reading sections of the raw data to
determine whether the findings were plausible based on the data. The researchers engaged in
an on-going dialogue about each transcript.
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Findings
Through this analysis we identify themes that relate to the participants’ representations
of their selfhood in relation to antidepressants. These themes were not mutually exclusive and
many participant accounts contained a combination of these different kinds of selfhood,
sometimes in apparent contradiction with one another.
A Diagnosed Self
Participants described how in the process of first being prescribed antidepressants, they
came to understand their distress as a problem with a label. Some felt that it made their
problems seem “more real,” and that it meant acknowledging that they had difficulties. As one
participant explained: “I felt like it was the end of the line, and I just had to acknowledge I had
a real problem.”
Most were given a formal label of depression which they felt lent legitimacy to their
experiences and demonstrated that their problems were “serious.” One participant explained
that receiving her psychiatrist’s diagnosis made her feel like, “it’s not just like me making it
up, it is actually as bad as I think it is kind of thing.” Other participants also conveyed that,
without the medical diagnosis, their problems would not be taken seriously. As one young
woman put it: “I was actually really worried that she would tell me that there was nothing
wrong with me or something. So, it was a relief to hear actually it was depression.” In this
way, being given a label and taking antidepressants eliminated questions in these young
women’s minds about whether or not they were allowed to feel as they did.
A number of the participants recalled a history in which their distress had been
downplayed or treated as an expected part of being an adolescent girl. One participant
explained how her doctor responded to her disclosure of distress:
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She just thought, I was a teenager at that time, it was just teenage thoughts and emotions
and there’s nothing really to it, so she kind of downplayed it, which didn’t leave me in
a good position because it’s just like wow, if it’s just nothing then why am I feeling this
way and why am I feeling so hopeless.
The doubts that the young women expressed about being taken seriously also appear to have
been internalized in the participants’ own self-understanding as the following quote suggests:
“I think I just sort of saw it as just like being a teenager really and just being angsty and all that
kind of stuff rather than this is like an issue, yeah.” In retrospect, she said that she felt that it
was difficult for her to “figure out” that she was depressed because teenagers are “emotionally
volatile anyway.”
Despite participants describing relief in response to receiving a diagnosis and an
antidepressant prescription, this experience also led to negative changes in the way that they
saw themselves. They used a range of words to describe how being diagnosed as having a
problem made them feel, including “a failure,” “not coping,” “defeated,”, “damaged,” and “not
normal.” One participant elaborated on how receiving her first antidepressant prescription
made her feel:
I felt like it kind of, it made me feel like different, it made me feel kind of like damaged
almost… it just made me feel kind of like crazy almost, not crazy but like just different
than other people.
For the young women in this study, accepting an antidepressant prescription countered
ideas that they were ‘making up’ their distress but also raised some significant challenges for
their selfhood.
An Ill Self
Many of the participants used the language of physical illness to describe themselves
during periods of distress, often referring to themselves as having been “unwell’ or “sick”
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during these times Taking antidepressants seemed to confirm an illness identity as the
following quote suggests: “You know the fact that you’re taking a pill was an indication that
you’re really, really sick and you know so that’s sort of proof that you’re not coping and you’re
sick.”
While most participants seemed aware of the contribution of difficult life events to their
distress, taking antidepressants seemed to necessitate at least a degree of acceptance of a
biochemical view of their emotional experience. Participants sometimes seemed to be
searching for a way to reconcile the impact of difficult circumstances with a biochemical view
of the self as the following quote illustrates: “Well I know that what you experience in the
outside world and your life can affect your brain and the way it works and everything that is
happening in you.”
Most narratives suggested that there was comfort in accepting this view of their
depression. One participant explained how in spite of having some uncertainty about the role
of biochemistry in her depression, adopting this model brought legitimacy for her distress: “It
meant that, it allowed me to justify to myself. I mean I don’t really know whether that whole
biological model is true or not but it meant that I was able to justify it.” She elaborated the
need for justification particularly in relation to other people’s social expectations adding; “[I
can] justify it I guess to mum and to others too, that it was a biological thing.”
The overt or tacit acceptance of a biochemical basis for their distress also brought with
it a range of challenges for the young women’s selfhood. Taking on a view that they had some
kind of biochemical imbalance brought with it a sense of helplessness associated with an illness
identity. One young woman, for example, talked about becoming “institutionalized” and said
that it was possible to get stuck in the “sick role.” Several participants said that they felt that
being on antidepressants underlined the fact that they could not “cope” on their own. One
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participant, for example, said that being on antidepressants made her feel “like I couldn’t
manage my psychological issues myself without a pill.”
The implicit association between antidepressants and biological illness seemed to bring
legitimacy to the young women who feared they might not otherwise be taken seriously, but
also positioned them as helpless and reliant on medication.
A Normal Self
Many of the participants in this study felt that their distress set them apart from others
in their adolescence and early adulthood, and some alluded to antidepressants contributing to
a sense of normality. One participant for example explained how ‘depression’ had left her
feeling “sad and tragic” through her teenage years. She explained how she had tried to hide her
struggles from those around her and to pass for normal amongst her peers. When this failed
she “sort of became that was who I was” and “what I built my identity around.” With many
participants having experienced a disruption to selfhood during their teenage years,
antidepressants seemed to bring the welcome possibility of being ‘normal’. One participant
expressed it like this:
For me it makes me feel how I imagine how everyone else feels. I love it. Like I feel
like I experience highs and lows and then, as any normal person would. I don’t feel like
I am always low or drugged up on a high or anything like that, I just feel normal.
For some antidepressants also facilitated not only feeling better within themselves, but also
believing that their social functioning had improved. Several participants spoke about how
antidepressants enabled them to ‘fit in’ and find friends in a way that they hadn’t previously
been able to do:
But now I’m I guess like an average person which is good. Because I used to think
myself as different from my friends and whatnot. But now I’ve got a few good friends.
It’s good.
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But while some narratives described a more normal self with antidepressants, other participants
described how the appearance of ‘normality’ brought with it what they experienced as a loss
of self. One participant articulated how being on antidepressants made her feel as though she
was no longer her authentic self. She described how she felt antidepressants had muted her
‘real self’ which was “loud,” “impulsive” and a “little bit crazy,” On antidepressants, she said,
she lost interest in the things around her and in her relationships with friends. Other participants
spoke about feeling “flat” or “numb” on antidepressants. One participant explained how she
felt she lost something of herself on antidepressants:
And so I did notice just little things in my personality just weren’t there like um
obviously caring about my friends which is a big thing and um just little things like I
noticed once I’d come off them like singing along to music, like I stopped doing that
and stuff. I just didn’t really exist I guess.
A few participants articulated the internal experience that antidepressants that although
antidepressants had made them behave more ‘normally’ it had made them feel strange and
different:
Yeah it just kind of made me feel like I wasn’t quite normal anymore like it just kind
of made me feel like it was a point of difference. Yeah, it just made me feel like weird,
like I wasn’t normal. I don’t know how to describe it other than that, but like just
different, yeah.
Participants’ accounts conveyed the value of finding a more functionally normal self
on antidepressants but also losing a sense of a more vital, idiosyncratic self for some,
paradoxically, felt less normal.
A Stigmatized Self
Participants spoke about how taking antidepressants also produced a stigmatized self.
A number of participants articulated their expectation that taking antidepressants would elicit
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judgements from others. Several said that they chose not tell anyone that they were taking
antidepressants. As one participant explained, “I just thought I can’t be bothered being judged
for it.” Another suggested that that being on antidepressants made her feel that she owed
everyone she spoke to an explanation “like an AA introduction.”
While most of the young women in this study described having some support from
close friends and family, these same communities were also the source of some of the more
severe judgements that they received about their antidepressants use. One participant, for
example, explained how her family who lived in a rural area would struggle to understand why
she was using antidepressants. She imagined her mother saying “that’s [her] and she’s
depressed and she probably takes drugs and stuff, you know.” She explained that when she
tried to speak to her mother about it, she would change the subject.
Several other participants also described negative reactions from family members about
them being on antidepressants. One participant explained that her mother “didn’t understand
that [she] was sick and I needed them.” Another said that her mother said “it was just like
psycho mumbo jumbo and someone had just put the ideas in my head, because I presented as
absolutely fine, you wouldn’t have known anything was wrong. So she didn’t necessarily
believe it.”
Some young women felt that they had others in their lives who “meant well” and wanted
to help, but did not understand what they were going through. One young woman talked about
her grandmother trying to “cheer [her] up” by getting out travel books from the library for her,
since this was something she usually enjoyed. She said of people in general, that there can be
“a lot of judgement,” and that people think “you can just cheer yourself up, but you can’t. You
do need something beyond, even just a friendly face, you need something far beyond that to
get out of it.” Similarly, another participant, said she felt like her friends were trying to “fix
her,” and would offer her advice, like “if you just get up and you put on your favorite t-shirt
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and you go out and you put a smile on your face and it will all be okay.” In these cases, friends
and family were portrayed as not understanding how “serious” their difficulties were, and
therefore were not fully accepting of their illness identity.
In response to this, participants would turn to friends and family members who they felt
understood them better. Some said that opening up about their experiences changed existing
relationships in positive ways, and contributed to them forming new relationships. One
participant, for example said of a work friend, “Yeah I had had a couple of breakdowns at work
and so yeah she kind of needed to know what was happening, and once I had explained the
whole situation, we became really good friends after that.”
Participants’ narratives suggested that they expected that their antidepressant use would
be negatively judged by others. In close relationships their primary concern was that their
distress would not be taken seriously which led to judgements about their antidepressant use.
Participants actively fended off stigma by, in some cases, hiding their antidepressant use and
in others by seeking out people who would understand them.
An Uncertain Self
Participant accounts suggested that many were unsure about whether to attribute
changes in their wellbeing to themselves, or to the antidepressants that they were taking. Some
of those whose lives had improved after they began taking antidepressants, felt unsure whether
it was antidepressants, or other factors, such as lifestyle changes, that had made a positive
difference. As one participant explained that “so much happened in that time, so it’s quite hard
to tease out kind of the true effects if you like of the antidepressants.
Participants not only had difficulty attributing positive change to antidepressants, but
they also couldn’t decide whether negative experiences could best be attributed to
antidepressants or to themselves and their difficulties. One participant, for example, articulated
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her difficulty in deciding whether her problems with memory and concentration were a feature
of depression or a product of the antidepressants:
I used to be quite a sharp thinker and didn’t really have trouble writing anything and
like since like about two years ago I just have like writer’s block….If it’s an effect of
depression then it will go away if I’m feeling better but if it’s a side effect of medication
that will mean it will be like this until I get off it or I have to change another one.
As participants experienced going on and off antidepressants at different times, this
situation became even more confusing. One participant, for example, described going off
antidepressants as being a difficult time in her life, but said that at that time, she was unaware
that she may have been going through withdrawal from this medication, and wondered if
withdrawal contributed to this. Another participant similarly, said that it took her a “couple of
months” to figure out that the emotional numbing she was experiencing was the result of taking
antidepressants and not just “her.”
Participants also experienced changes during the process of taking the same
antidepressants, adding to the complexity of what changes in the self could attributed to the
medication. Not only were participants confused about whether to attribute changes in their
wellbeing to antidepressants or to something else, but they were also unclear about whether
their emotional experience was being influenced by the antidepressants they were taking, or
was in fact an expression of their ‘real selves’. As one participant put it, she wondered “Is what
I’m feeling the drugs or is what I’m feeling me?” People also wondered who they would be
once they stopped taking antidepressants. Another participant explained, “I guess I really don’t
know who I’d be if I came off them. Like, I don’t know where my natural space is at anymore.”
While some participants appeared to be actively engaged in a process of trying to work
out who they were, this seemed more difficult for participants who had been on the medication
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for longer periods. One participant who had been on antidepressants for six years explained
that she had given up on trying to make sense of her identity:
Over time I just stopped thinking about whether it was the drugs or whether it was me.
After 6 years you’ve kind of got to give up on that question if it’s left unanswered…
You’re just going to be like, well it’s not coming, so I’m going to stop trying….
This last quote highlights the impact of longer term antidepressant use on this
participant. This was particularly relevant for a number of other participants who had spent
most of their adolescent and early adulthood taking medication as the following participant
graphically conveys:
No, I realized, like when I started, sort of after the year of going on and off medications
and trying to keep track of different ones through the day or anything, I was just
exhausted by it. It was stress in itself worrying about it all and I was quite hazy all the
time, because I was sort of coming off one thing and onto the other and I couldn’t really
remember why I had come off one or onto the other and I didn’t know what was normal
anymore. So the baseline for am I better or not wasn’t clear. I didn’t know if I was
improving or if it was making it worse because I couldn’t actually remember what it
was like not being on medication.
Participants’ accounts conveyed the difficulty of constructing a coherent sense of self when
they were unsure about whether what they were experiencing was because of the medication
or other aspects of themselves or their lives. This was particularly difficult for those who could
not have a clear sense of themselves prior to taking antidepressants.
A Powerless Self
Taking antidepressants brought the participants into a regular relationship with a health
professional who prescribed the medication. Many of the participants had attended an initial
medical appointment at the insistence of their parents, usually their mother. While their parents
20
were often described as being supportive, this meant that the young women were frequently
positioned as children in their first interactions with a prescriber.
Although some participants described having been given good information and a choice
about taking antidepressants, most felt pressured to some degree by their doctor or other adults
in their lives. Participants conveyed the difficulty that young women might face in standing up
to an adult health professional, who in some cases was also male. One participant described
the doctor’s appointment which led to her being prescribed antidepressants as follows:
He was just pretty much like take them, don’t go home Google this, what it is or
symptoms, just take them. … So he said just take them, I don’t care what anyone else
says, just take them. He was very forceful but in a nice way, not mean, but you just
need to take them at this point.
Another participant explained how seeing her childhood doctor made it particularly difficult to
speak out:
Well the thing with my doctor is she is my family doctor so I’ve been going since I was
little but she’s the sort of person, it’s just like you need to do this, so do it. I didn’t
actually know anything about the medication.
For young people, it seems that there was little attention paid to the usual practices of informed
consent in health settings as this participant indicates: “I didn’t really get a choice over it. It
was this is what you’re taking, do as you’re told type approach. It was no sort of informed
decision making stuff.”
The participants, who were in many cases teenagers, felt themselves less
knowledgeable or able to ask questions about antidepressant use than an adult might in similar
circumstances.
Several of the young women also described how they had felt inconsequential in their
busy doctors’ offices. One participant for example said she felt like “just another person on
21
their list” and that “I felt like they weren’t like, they cared but they didn’t really remember who
I was or like know who I was other than their notes.” Several others spoke about how having
only brief appointments with their doctor, made them feel unimportant. Many also complained
that there had been little follow up from their doctors after the initial prescription
A few participants described how, over time, they had been increasingly able to assert
themselves in appointments with their doctors, and began to feel more “in control” of their
medication use. One participant described how she had been able to refuse an additional
medication suggested by her prescriber, explaining: “But if that was 10 years ago, I would have
gone with it. Yeah, so at the time I was just doing whatever the doctor thought was best really
and just hoping that would work.” However, overt assertiveness of this kind appeared rare in
participants’ narratives and most of the young women opted to assert greater control in a covert
manner, for example, by choosing to stop taking antidepressants without the input of their
prescriber.
Participants described how their engagement with health professionals over
antidepressants made them feel powerless and their distress, unimportant. While some learnt
to assert themselves more actively in these relationships over time, most experienced
themselves as being subject to the power of the prescribing health professional.
Discussion
The impact of antidepressant use on young women’s selfhood needs to be understood
within the wider context of the way that gender and youth shape identities in contemporary
societies. The young women in this study appeared to be motivated by concerns that their
distress would be trivialized and treated as an expression of the emotional volatility expected
of young women (Sparks, 2002). Against this context, receiving a diagnosis associated with a
biochemical etiology and which requires the use of medication, was seen as a source of relief
and legitimation for the women. However, the acceptance of the diagnosis, its etiology and the
22
medication that goes along with it seemed to entail the acceptance of an illness identity which
carried other more negative meanings for the young women in this study. In particular,
accepting the power of the medication in dealing with their problems meant giving up a sense
of control over their lives and the autonomy that young people value so highly (Gibson &
Cartwright, 2013) and which is reiterated in the idealized representations of young women-
hood in post-feminist societies (McRobbie, 2007).
In addition to providing legitimacy for their distress, antidepressants also offered the
possibility of a ‘normal’ selfhood to these young women. Having struggled with feeling
different and under pressure to conform to expectations, antidepressants seemed to enable
young women to find a degree of acceptability that they sought. This echoed the findings of a
Swedish study of young people and depression described the key theme of young people’s
narratives as, “my greatest dream is to be normal” (Danielsson, Bengs, Samuelsson, &
Johansson, 2011, p. 612) and fits with developmental literature which recognizes the
importance of fitting in for young people (Milner, 2013). Most of the young women in this
study eagerly traded more vital and perhaps eccentric parts of themselves for a self that might
be more muted, but was more acceptable to others. Emotional numbness was reported as a
side effect of antidepressants by two thirds of 1829 New Zealand antidepressant users who
took part in a survey from which the current study’s participants were recruited (Read,
Cartwright & Gibson, 2014). The potential for antidepressants to dull strong emotions during
a period in which emotional experience is thought to be central to development is particularly
concerning (Crone & Dahl, 2012).
One of the most important analytic findings in this study was the loss and uncertainty
the young women experienced in relation to their selfhood. While similar confusion about
selfhood is recognized to be common amongst adults using antidepressants (Malpass, Shore &
Sharpe, 2009), this phenomenon takes on more significance for a group who have begun taking
23
antidepressants before they had developed a strong sense of selfhood. Unlike adults who might
wonder whether they experienced their ‘true self’ on antidepressants, these young women had,
in many cases begun taking antidepressants at a time traditionally associated with self-
discovery during which they are still negotiating key aspects of their identity (Silva, 2012). It
was particularly poignant to note how those who had been on antidepressants for longer periods
had given up the quest to make sense of ‘who they were’.
In constructing their selfhood, the young women in this study also appeared to have
been influenced by the communities they inhabited, their friends, their families and their health
providers. While some of these communities had been were supportive, the young women in
this study had to negotiate real and anticipated stigma from people they worried would judge
them for taking antidepressants and, in some cases, this appeared to have become a guilty secret
that set them apart from others. The potential for their choices to be stigmatized might have
been particularly strongly felt by the young women in this study, given the importance on social
acceptance in this developmental period (Milner, 2013).
The young women in this study also experienced challenges to their selfhood through
their engagements with health professionals around antidepressant prescribing. While many
patients struggle to exercise power in the face of the authority of a health professional, young
people are likely to be at a particular disadvantage in these settings (Harper, Dickson &
Bramwell, 2014). Researchers have pointed to the importance of having young people involved
in decisions about interventions designed to address depression (Simmons, Hetrick & Jorm,
2011). The failure to do this may impact on young women’s developing sense of agency.
While this analysis suggests that using antidepressants poses many potential challenges
young women’s developing selfhood it also demonstrated the potential for young women to
negotiate these successfully and to construct a more positive selfhood in spite of these
challenges. The young women in this study sought legitimacy and normality but they also
24
sometimes resisted the constraints of these safer selfhoods and recognized the value of a more
vital and agentic self. Some actively fended off stigma and found support that they felt matched
their own needs. A few had also learned to claim their own power in dealing with health
professionals over time. An evaluation of the potential impact of antidepressants on young
women’s selfhood also needs to be weighed against the influence of distress and depression
(and the life circumstances that might contribute to this) on young women’s selfhood. We
cannot know what kind of selfhood challenges these young women would have faced had they
not taken antidepressants.
The current research has focused on the experiences of young women who are largely
New Zealand European. While the sample reflects the significantly higher rates of
antidepressant prescribing in this group (Wilkinson & Mulder, 2018), it would nonetheless be
of value to gain the perspectives of members of other demographic groups and across different
cultures where experiences are likely to be different to those of this this group of participants.
In particular, more targeted research with ethnic minorities, such as Māori and Pacific Island
youth would be important in the New Zealand context. It would also be useful to conduct
longitudinal studies that might provide insight about how narratives of selfhood change over
time for those who have continued taking antidepressants, as well as those who have stopped
taking them. Further knowledge on the perspectives of family and friends who are close with
young women who take antidepressants, might shed light on influences such as support and
stigma in the social contexts that they inhabit.
While taking antidepressants is recognized to have significant effects on adults, its
effects on young women’s developing sense of self are likely to be even more profound. Youth
is a period of life within which identity issues are paramount and people begin explore narrative
possibilities that will contribute to their future selfhood (McAdams, 2011). While
antidepressants offer young women legitimacy for their distress and the possibility of ‘normal’
25
functioning, they also represent a significant challenge to selfhood at a time when it is just
beginning to take shape.
Prescribers should be wary of the potential of antidepressants to disrupt the processes
that contribute to a relatively coherent and positive sense of self and to be aware of their own
role in supporting young women through this. This research has highlighted that young women
can feel pressured into taking antidepressants by medical professionals, and are not always
given the information that they require to make an informed choice. As it has been discussed,
this has a negative impact on their sense of self. Professionals providing care to young women
who are, or have used, antidepressants might need to explore the effects that these have had on
their identity development and work with them to help construct a more solid sense of self.
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A version of this manuscript has been published in Qualitative Health Research and can be
found at:
Wills, C., Gibson, K., Cartwight, C. & Read, J. (2019). Young women’s selfhood on
antidepressants: ‘Not fully myself.’ Qualitative Health Research.
https://doi.org/10.1177/1049732319877175
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... One particularly worrying consequence of this, in the context of individual suffering, is the fact that some people with psychiatric diagnoses may even lose the ability to understand their mental states as something that is directly connected to the lives they live, e.g., the suffering of somebody who was abandoned in a romantic relationship could be explained by themselves (and mental health professionals) as a "relapse of depression"-one caused by "chemical imbalances"-without realizing at all and disregarding the impact of the psychological or social situation [60]. The use of medication can also have a detrimental effect on identity [61]. ...
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The article proposes a rough outline of an alternative systemic approach to mental health issues and of a more humane mental health care system. It suggests focusing on understanding mental distress as stemming from problems in living, using medications as agents facilitating psychotherapy, or as a last resort and short-term help, according to the principles of harm reduction. It argues that understanding drugs as psychoactive substances and studying the subjective effects they produce could lead to better utilization of medications and improvements in terms of conceptualizing and assessing treatment effects. Qualitative research could be particularly useful in that regard. It also advocates a radical departure from current diagnostic systems and proposes a synthesis of already existing alternatives to be used for both research and clinical purposes. Accordingly, a general idea for an alternative mental health care system, based on a combination of Open Dialogue Approach, Soteria houses, individual and group psychotherapy, cautious prescribing, services helping with drug discontinuation, peer-led services and social support is presented. The proposition could be seen as a first step towards developing a systemic alternative that could replace the currently dominating approach and mental health care system, instead of focusing on implementing partial solutions that can be co-opted by the current one.
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Despite older adolescence being a risk period for the development of mental health concerns, mental health service engagement is low among 16- to 18-year-olds. As therapeutic attendance is linked to clinical outcome, it is important to understand engagement in this population. There is a paucity of research looking specifically at the older adolescent engagement phenomenon. Previous qualitative research into adolescent experiences has provided rich and detailed results. Interpretative phenomenological analysis was chosen as the methodological approach. Ten 16- to 18-year-olds were recruited from two London-based child and adolescent mental health services. Each young person was interviewed to understand his or her personal experience of engaging in mental health services, and associated engagement barriers and facilitators. Interviews were transcribed and underwent analysis. Analysis revealed ten subthemes subsumed within four superordinate themes: engagement begins at help seeking, strength of inner resolve, evolution of the self and in the clinic room. Themes are discussed in detail. Conclusions are drawn in relation to previous theory and research. When considering 16- to 18-year understandings of the engagement phenomena, key elements include clinician and service developmental appropriateness, negotiation of developmental tasks in relation to engagement, experience of the physical building environment, and awareness of service policy. Suggestions for clinical practice in relation to engagement facilitators and threat are made, and recommendations for future research proposed.
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Following the FDA black box warning in 2004, substantial reductions in antidepressant (ATD) use were observed within 2 years in children and adolescents in several countries. However, whether these reductions were sustained is not known. The objective of this study was to assess more recent trends in ATD use in youth (019 years) for the calendar years 2005/6–2012 using data extracted from regional or national databases of Denmark, Germany, the Netherlands, the United Kingdom (UK), and the United States (US). In a repeated cross-sectional design, the annual prevalence of ATD use was calculated and stratified by age, sex, and according to subclass and specific drug. Across the years, the prevalence of ATD use increased from 1.3% to 1.6% in the US data (+26.1%); 0.7% to 1.1% in the UK data (+54.4%); 0.6% to 1.0% in Denmark data (+60.5%); 0.5% to 0.6% in the Netherlands data (+17.6%); and 0.3% to 0.5% in Germany data (+49.2%). The relative growth was greatest for 1519 year olds in Denmark, Germany and UK cohorts, and for 1014 year olds in Netherlands and US cohorts. While SSRIs were the most commonly used ATDs, particularly in Denmark (81.8% of all ATDs), Germany and the UK still displayed notable proportions of tricyclic antidepressant use (23.0% and 19.5%, respectively). Despite the sudden decline in ATD use in the wake of government warnings, this trend did not persist, and by contrast, in recent years, ATD use in children and adolescents has increased substantially in youth cohorts from five Western countries. http://authors.elsevier.com/a/1Sgjf,L21DWJPv
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Objectives: This study examined national trends in 12-month prevalence of major depressive episodes (MDEs) in adolescents and young adults overall and in different sociodemographic groups, as well as trends in depression treatment between 2005 and 2014. Methods: Data were drawn from the National Surveys on Drug Use and Health for 2005 to 2014, which are annual cross-sectional surveys of the US general population. Participants included 172 495 adolescents aged 12 to 17 and 178 755 adults aged 18 to 25. Time trends in 12-month prevalence of MDEs were examined overall and in different subgroups, as were time trends in the use of treatment services. Results: The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors. Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents. Conclusions: The prevalence of depression in adolescents and young adults has increased in recent years. In the context of little change in mental health treatments, trends in prevalence translate into a growing number of young people with untreated depression. The findings call for renewed efforts to expand service capacity to best meet the mental health care needs of this age group.
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Background Women are twice as likely to experience depression and use antidepressants as men. Personal agency protects against depression; however, social factors contribute to lower levels of agency in women. AimsThis study examines women's experiences of using antidepressant treatment along with the other activities and practices they engage in to support their recovery from depression. It aims to understand how these experiences promote or diminish women's sense of agency in regard to their recovery. Method Fifty women took part in telephone interviews focusing on experiences of antidepressants as well as personal efforts to recover. A thematic analysis examined the agency-promoting and agency-diminishing experiences of using antidepressant treatment and engaging in other activities. ResultsAntidepressants promoted agency when they gave women relief from depressive symptoms, allowing women to become more proactive in recovery. Women engaged in a range of activities they believed assisted recovery and hence enhanced agency. These included exercise, gaining social support, and engaging in therapy. Some, however, had shifted to long-term antidepressant use. Failed attempts to discontinue due to severe withdrawal symptoms, fear of a relapse, and the biochemical model of depression created a sense of dependence on antidepressants and thereby diminished personal agency in relation to recovery. Conclusions Antidepressants can support women to become agential in their recovery. However, long-term use signifies greater dependency on antidepressants, and personal agency is seen as insufficient. The fear of withdrawal symptoms and the biochemical model undermine women's sense of personal agency in relation to recovery.
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In this timely and insightful book, award-winning sociologist Murray Milner tries to understand why teenagers behave the way they do. Drawing upon two years of intensive fieldwork in one high school and 300 written interviews about high schools across the country, he argues that consumer culture has greatly impacted the way our youth relate to one another and understand themselves and society. He also suggests that the status systems in high schools are in and of themselves an important contributing factor to the creation and maintenance of consumer capitalism explaining the importance of designer jeans and designer drugs in an effort to be the coolest kid in the class.
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The language of psychology is all-pervasive in American culture-from The Sopranos to Oprah, from the abundance of self-help books to the private consulting room, and from the support group to the magazine advice column. Saving the Modern Soul examines the profound impact of therapeutic discourse on our lives and on our contemporary notions of identity. Eva Illouz plumbs today's particular cultural moment to understand how and why psychology has secured its place at the core of modern identity. She examines a wide range of sources to show how self-help culture has transformed contemporary emotional life and how therapy complicates individuals' lives even as it claims to dissect their emotional experiences and heal trauma.