Description of included studies
Our search identified 9,188 studies, which was reduced to 6,540 after deleting 2,648 duplicates (see Figure 1). Following screening of titles/abstracts we excluded 6,351 studies for irrelevance. Following full text review of the remaining 188 studies we excluded 177 based on our exclusion criteria, included eleven studies and added three more based on hand searching the references from the selected studies, identifying 14 eligible studies (24, 41-53), which we included in this meta-synthesis. We achieved 100% agreement on study eligibility between four authors. Characteristics of each study are shown in Table 1, including an assessment of study quality using CASP criteria.
The total number of participants was 388, with sample sizes in each study ranging from 5 to 107. Participants’ ages ranged from 11 to 30 years, and roughly three quarters were female (n=288). Dates of publication ranged from 2002 to 2019, and studies originated from the United States, United Kingdom, Finland, Belgium, France, Canada, Australia, and Germany. Thirteen studies were published in peer-reviewed journals, while one study was an unpublished PhD dissertation (53). One study was a meta-synthesis of six qualitative studies (43), which included one identified in our own search (44). We decided to include this meta-synthesis as a unified whole rather than disaggregating its included studies because a number of those studies were unpublished theses that were unavailable to us.
All studies involved individuals with a history of depression, whilst two studies included participants with depressive episodes in the context of bipolar disorder. In those two studies an unknown proportion had bipolar in one (53), whilst two out of nine participants had bipolar in the other (49). Most studies (n=12) collected interview data, while two studies used free text from written self-reports. Included studies used a range of qualitative analytic methods: thematic analysis, interpretative phenomenological analysis, grounded theory, discourse analysis, framework analysis, hermeneutic phenomenology, content analysis, and comparative method analysis.
Our thematic synthesis of 14 eligible studies identified four analytic themes: (1) social withdrawal due to poor mental health, (2) non-disclosure of depression contributing to social distance (with four sub-themes), (3) the desire to connect, and (4) paradoxes of loneliness and depression. Quotes given in italics denote primary data.
Theme 1: Social withdrawal due to poor mental health
A key theme we identified related to the debilitating nature of depressive symptoms, which made it very hard for some young people to engage with others. Nearly all studies (n=13) described the experience of depression as causing those individuals to withdraw from others, relating this to difficulties in being around others due to low motivation and low energy.
“There would be days that I just couldn’t get out of bed. I didn’t want to face people. I didn’t want to look at anybody, I just wanted to stay there and I guess just sulk by myself, and I just didn’t have any energy.” (Female, 19 years old, USA sample) (43)
Some individuals described feeling better when isolating themselves from peers, because being around others was so emotionally draining. “I come home it's just kind of like a relief”, explained Lana (14 years old, UK sample), who had been bullied at school for reasons unspecified (50). Some participants avoided others by spending time in their rooms or going for walks alone. One 19 year old female participant from the USA explained, “I just kind of wanted to be by myself.” (41)
Participants described having stopped participating in activities they had previously enjoyed or not feeling able to fully engage in such activities. A 19-year old female participant from the USA, who had taken an active role in the performing arts since the age of two years explained,
“I was in show choir and throughout that year I just didn’t really enjoy it. I was fine with standing in the back, which really wasn’t like me. My wanting to be in the back just wasn’t normal.” (41)
Low self-esteem seemed to affect some young people sampled, who felt that their depression had worsened their insecurities, leading them to withdraw socially. The depression had apparently eroded their belief that anyone could find them likeable, resulting in them withdrawing to avoid other people.
“I become even more withdrawn than I normally am, and it’s based on the insecurity, and it came up the unlikeability thing again, that I’m not likable inherently so what’s the use of pretending that I am because eventually they are going to find out.” (Sarah, female aged 25-30 years; Canadian sample) (45)
Participants also spoke of an inability to feel affection from others: “When you’re depressed you feel like you don’t have anybody.” (Tina, female, aged 13-18 years, USA sample) (44). The syndrome of depression set young people apart from their peers and made them feel different. This change was noted by others, even if they did not necessarily recognise it as depression, and this could lead to others’ withdrawal. The sense of rejection was apparent in young people who coped by isolating themselves, thus compounding their sense of differences between them and others.
“People just started drifting away, like they were asking, "What's wrong with you?" I wanted to ask them, "Why don't you talk to me anymore?" I felt they were saying "You're different now!" I just began to hide away a lot and I would say, "I just want to be alone”. (female, 13 years old, USA sample) (53)
Theme 2: Non-disclosure of depression and social distance
The second theme, emerging from 12 studies, was more explicitly related to feelings of loneliness. As young people dealing with depression were hesitant about disclosing their depressed feelings to people in their social networks, they avoided being open about their true selves. This sense of otherness through concealment enhanced participants’ feelings of loneliness. Some individuals described being very aware of putting up a façade and of making extensive efforts to maintain this front to avoid talking about their mental health issues.
“I would put on a smile for my parents and my siblings. Whenever somebody would leave and I knew I was going to be alone, they would ask me, “Are you going to be alright?” And I would say “Yes, of course,” because I didn’t want them to know what I was dealing with. But, it was a living hell. I put up a really good façade for them, like all cheery and happy, nothing’s wrong.” (Female, 21 years old; USA sample) (41)
A range of reasons were given for the non-disclosure of depressed mood, summarised in the four sub-themes below.
Subtheme 2.1 Fear of being judged
Young people in the included studies commonly expressed fear of being judged negatively if they identified themselves as suffering from depression, or of being perceived as unbearable or embarrassing if they vented their feelings. The negative consequences they feared included social exclusion and isolation, as borne out by their experiences:
“I cannot talk about my sadness, in fact, I don’t dare to talk about it, because then you are considered as a weak person. I see that some people feel pity for me, but they don’t talk to me, they prefer to run away because they are afraid and do not know how to react to someone who is sad.” (Female, 18 years old; Belgian sample) (24)
“If I could talk to them [friends] I would, but I just didn’t feel like I could talk to them. They would keep on going, ‘You’re weird’ or something.” (Sandra, female, 13-18 years old, USA sample) (44)
Subtheme 2.2 Preserving friendships
Another reason for not disclosing their depression was that the young people sampled clearly valued their friendships and wanted to preserve existing networks. They feared losing these connections if they shared their feelings of depression. There was also a fear of burdening others, in that by not disclosing their depressive thoughts they hoped to minimise the negative impact of their depression on others. Many adolescents had experienced negative changes or the ending of friendships as a consequence of mental health problems and this reinforced their reluctance to reveal their feelings to friends.
“I’m afraid that friends and signiﬁcant others can’t see me the same way as before or something might change between us if I told them all my troubles. I don’t want to bother anybody with my worries.” (Unknown gender, 15-17 years old; Finnish sample) (42)
Subtheme 2.3 Difficulty explaining oneself
Beyond deliberate efforts to avoid talking about their feelings, young people also found it hard to explain why they felt depressed. Pressure to explain themselves arose from members of their peer group, who struggled to comprehend their experiences, expressing this through intolerance. Their own inability to formulate or articulate an explanation frustrated young people with depression and had the effect of widening the gulf between them and others.
“When you feel bad, you need to have an external explanation for why you have these feelings, because the fact that you feel bad must be caused by something. Participants stated that they often received the question: ‘Why are you feeling so bad?’ Adolescents shared that they cannot give a constructive answer because they do not know why they have these feelings. They could not give explanations because there were no specific causes for them. Due to the inability to provide a real explanation regarding the causes, their feelings and depression are not recognized by others.” (24)
Subtheme 2.4 Perceived futility of explaining oneself
Experiencing depression engendered a realisation of being different from one’s peers. This gave rise to the belief that others would not understand one’s situation and that there was therefore no point in discussing it. Young people with depression indicated that they feared others were likely to trivialise, dismiss or ignore their depressive symptoms. Again, their previous negative experiences of others failing to understand them taught some young people not to disclose their feelings. The lack of any incentive or opportunity to confide and feel understood made young people feel very lonely.
“Having others reach out, however, was not always beneficial. Some participants, especially females, did not feel comfortable opening up to those who reached out to them. These participants did not believe the other person would understand what they were going through, believed their problems were ‘no one else’s business’ or doubted the person’s motives for reaching out.”
“Despite the fact that all the individuals in this sample acknowledged social support as an important part of their daily lives, the belief that others cannot understand their experiences often caused individuals to feel alone.” (46)
Theme 3: The desire to connect
Despite young people reporting a tendency to disengage from certain social interactions, they still expressed a desire for connection and a desire to feel ‘normal’.
“At the same time, the adolescents hoped to have more friends and to be included in their peer group. In addition, they wished to have a good time with the friends and to have somebody to talk to about their problems and feelings.”
“Most individuals have a strong need to connect and have positive relationships with others especially middle school students.” (53)
In this sub-theme we identified a conflict with the experiences described in sub-themes 2.3 and 2.4 above, in that although some individuals expressed a wish to talk about their issues, they also experienced difficulties in doing so. Such barriers included a fear of the consequences, particularly the threat of rejection (and perhaps stigmatisation) from peers. To address this, some preferred to share their problems with people who they knew had faced the same mental health issues in preference to their wider peer group, amongst whom it was not always clear who had experienced depression themselves.
“Shadow clearly had the wish to disclose to someone, which he expressed in a wish for some kind of group therapy to meet people where he could actually speak about his problems: “And maybe, that you can talk about it in a group that you can say: “I am [Shadow], I have this and that problem. What do you think, what is your impression, what is your problem?” . . . Because I can’t possibly walk into my classroom and say: “you know what happened to me?” Well, I could, but . . .” (Male, 15-19 years old; German sample) (51)
Theme 4: Paradoxes of loneliness and depression
This theme described a number of paradoxes or vicious cycles that were apparent in various forms across a number of studies. Whilst some young people talked about a need or a tendency to withdraw socially, this came with an awareness that such avoidance could create or worsen feelings of loneliness.
“During their depressive experiences, participants felt a distinct separateness from others and often chose solitude over being with others even when feeling lonely”. (44)
“Being around people was, was always a bad thing for me. I constantly felt the need to be alone . . . and I always felt like interacting with other people was difficult for me . . . Ya, that was confusing because I felt lonely but I didn’t feel like being around anyone at the same time” (Jeff, aged 25-30 years, Canadian sample) (45)
Some young people described their friends showing a form of understanding by not asking too many questions, but then feeling cut off because of an apparent absence of overt concern.
“Sometimes when some of my friends are ….. ok with ignoring me, with not asking about it, I feel like kind of I know it's ridiculous, but unloved. (Female, 17 years old, UK sample) (50)
Another trap that some young people described was a vicious cycle of loneliness and depression, was the suggestion that the manner in which they processed feelings about loneliness reinforced their depression.
“They were unable to initiate or sustain relationships because of feelings of severe discomfort around people. They described a cycle of feeling lonely, often as a result of their breakups, and then feeling depressed about the loneliness, causing a self-fulfilling prophecy by further alienating and self-isolating themselves from others.” (45)
A fear of stigma was also mentioned as a reason for withdrawing from others, but this came at the price of increasing loneliness. Sometimes a yearning to connect with others coexisted with an inability to be with them. However, where they withdrew from others, young people were prevented from getting support from others, thus increasing their sense of alienation from friends.
“While some disclosed their depression to friends, others withdrew, fearful of the perceived stigma and loss of status from being labelled as having mental illness…. However, retreating from others contributed to their loneliness and isolation.” (48)
The difficult choice that some young people faced, was between withdrawing socially to hide their depression and then feeling excluded, or remaining superficially socially engaged but living behind a façade in not disclosing their depression. In the latter case, the strain of concealing their low mood could create a sense of greater alienation from their peers.
“This process of social isolation was characterized by ambivalent feelings. Participants explained that on the one hand they feel the necessity to share their emotions with others, but on the other hand they felt it was impossible to do this. Consequently, they felt caught up in a vicious circle which made them feel alienated from themselves and from of their social world.” (24)
No suggestions were made by participants as to how to break such vicious cycles, but a note of optimism was sounded in relation to recovery from depression. During an episode of depression young people characteristically described the experience of yearning for a connection with others, feelings of being very different from others, and a perception that their problems were incomprehensible to their peers; all of which meant that when unwell, gaining a sense of connectedness was out of their reach. However, on recovering from an episode of depression, those who reflected back on those unwell periods had better insight into such traps and were able to see how a lifting of their symptoms removed many of the barriers to connecting with others.