Understanding Teen Expression of Sadness in Primary Care: A Qualitative Exploration

Introduction: The lifetime and 12-month prevalences of depression in adolescents are believed to be 11% and 7.5%, respectively. The prevalence of adolescent depression in primary care settings has been estimated to be twice that in community samples. It is often the role of the Primary Care Provider (PCP) to recognize and investigate early signs of depression in adolescents. However, there are barriers such as time, inadequate training, dearth of referral sources, and lack of health care coverage. We believe that understanding how adolescents express pre-depressive symptoms and coping strategies may help PCPs in depression prevention.

Methods: The PATH (Promoting Adolescent Health Study)—a large, multi-site, NIMH-funded, depression prevention trial of N=446 adolescents—was completed in 2016 at the University of Illinois at Chicago and Wellesley University. The screening process for the PATH Study included semi-structured diagnostic hour-long K-SADS-PL (Kiddie–Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime) interviews. We selected N=24 of these interviews from both sites for qualitative analysis to explore how adolescents express pre-depressive symptoms and coping. We conducted content analysis until data saturation occurred and patterns in the data emerged.

Results: Teens rarely stated they were “depressed.” Instead they used terms such as “stressed” or “sad” to describe themselves, stating these feelings came and went, or came in “bursts.” The majority noticed increased anger and irritability toward others. Teens mentioned new feelings of apathy toward prior interests. They overwhelmingly discussed marked difficulty falling and staying asleep. Consistently they noted school and pressure related to homework and expectations to succeed were sources of stress and difficulty. Family discord was identified as a major stressor related to mood worsening. Examples include: arguments with a parent or in the household, divorce, separation, and moving homes. Notably, many teens had visited their PCPs for physical illnesses such as ulcers, migraines, stomach pains, difficulty sleeping, and fatigue – all seemingly unrelated to expression of feelings of depression. Having friends to spend time with and talk to helped the teens cope with stressors.

Conclusions: The findings identify topics PCPs should tune into with teens, exploring with inquiry and probing during both annual and episodic visits. This research identifies these feelings as possible expressions of pre-depressive feelings expressed by teens. Recognition of these feelings as outward symptoms of pre-depression by the PCP would allow for connection to mental health services and allow for opening the discussion of mental health with the teen and parent.