Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Depression in Arab Adolescents: A Qualitative Study

Latefa Ali Dardas, PhD, PMHN, CP; Noordeen Shoqirat, PhD; Hana Abu-Hassan, MBBS, MRCGP, JBFM; Bilal F. Shanti, MD; Amjad Al-Khayat, PhD; Deborah H. Allen, PhD, RN, CNS, FNP-BC, AOCNP; Leigh Ann Simmons, PhD, MFT

Abstract

Depression rates among Arab adolescents are expected to rapidly increase necessitating research-based data to aid in planning effective strategies to implement primary prevention and treatment interventions. The current study aimed to capture Jordanian adolescents' experience of depression, identify perceived contributing factors, and assess their attitudes toward depression interventions. An exploratory, qualitative design was used to collect data from 92 participants (age range = 14 to 17) through 12 focus groups. Two main analytical themes and related subthemes were identified. The first theme focused on participants' perceived mental health status, Being a Depressed Adolescent, with two related subthemes: Symptom Profiles and Feelings of Uncertainty and Perceived Roots of Depression. The second theme focused on the experience of Living With Depression and encapsulated two subthemes: Seeking Supportive Resources and Escaping From Labeling. The study revealed gender differences in the recognition of depression symptoms, willingness to seek care, the ability to communicate symptoms, expectations of care, and views on the best sources of help. For girls and boys, the fear of being labeled as mentally ill contributes to poor engagement in, adherence to, and use of mental health services. A comprehensive approach that considers Arab adolescents' beliefs, attitudes, and experiences in conjunction with the family and social context is needed to address the burden of adolescent depression in Arab nations. [Journal of Psychosocial Nursing and Mental Health Services, 57(10), 34–43.]

Abstract

Depression rates among Arab adolescents are expected to rapidly increase necessitating research-based data to aid in planning effective strategies to implement primary prevention and treatment interventions. The current study aimed to capture Jordanian adolescents' experience of depression, identify perceived contributing factors, and assess their attitudes toward depression interventions. An exploratory, qualitative design was used to collect data from 92 participants (age range = 14 to 17) through 12 focus groups. Two main analytical themes and related subthemes were identified. The first theme focused on participants' perceived mental health status, Being a Depressed Adolescent, with two related subthemes: Symptom Profiles and Feelings of Uncertainty and Perceived Roots of Depression. The second theme focused on the experience of Living With Depression and encapsulated two subthemes: Seeking Supportive Resources and Escaping From Labeling. The study revealed gender differences in the recognition of depression symptoms, willingness to seek care, the ability to communicate symptoms, expectations of care, and views on the best sources of help. For girls and boys, the fear of being labeled as mentally ill contributes to poor engagement in, adherence to, and use of mental health services. A comprehensive approach that considers Arab adolescents' beliefs, attitudes, and experiences in conjunction with the family and social context is needed to address the burden of adolescent depression in Arab nations. [Journal of Psychosocial Nursing and Mental Health Services, 57(10), 34–43.]

Mental illness constitutes a major cause of health burden, disability, morbidity, and mortality across all countries worldwide. Mental disorders during adolescence are particularly significant, and global rates of adolescent depression have reached epidemic proportions. Ranked as the leading cause of years lost to disability among adolescents (World Health Organization [WHO], 2018), depression remains a significant, persistent, and debilitating problem that undermines social and school functioning and prompts substantial health services use.

As the transition period between childhood and adulthood, adolescence is a challenging stage of development in the human lifespan. Developmental changes occur across a range of domains, including physical, hormonal, intellectual, and emotional. These changes have a significant impact on how adolescents navigate and respond to their environment, including how common experiences, such as school bullying, aggressive behavior, and inappropriate sexual advances, affect them. Studies suggest that adolescents who experience depression are more likely to have maladaptive responses to common challenges and demonstrate delayed emotional, cognitive, and social development (Patton et al., 2016; Thapar, Collishaw, Pine, & Thapar, 2012).

In the Arab world, being an adolescent with depression proves even more challenging. Although Arabic countries have the largest segment of adolescents in the world with 38% of the population younger than age 14 (The United Nations, 2011), talking about or reporting mental illnesses such as depression carries a biased stigma within Arab communities (Dardas & Simmons, 2015). In addition, most Arab countries do not have a dedicated budget for mental health services as part of total health expenditures, and there is a limited number of psychologists, psychiatrists, and other mental health providers to provide services (Okasha, Karam, & Okasha, 2012). In fact, the WHO (2016) reported Arab countries among the least prepared to provide appropriate treatment for common mental disorders. To compound this issue, Arab countries are in a geographic area with decades of armed conflicts, violent wars, and refugee displacements that add to a heavy burden of socioeconomic, cultural, educational, behavioral, and psychosocial tolls (Amawi, Mollica, Lavelle, Osman, & Nasir, 2014). Unsurprisingly, depression rates among Arab adolescents are expected to face a rapid increase (WHO, 2016).

Jordan, a low- to middle-income Arab country, is like other Arab nations. It has poor natural resources and limited gross domestic product. For many decades, it has been a host country for millions of refugees escaping from the Palestinian–Israeli conflict, Iraq War, and Syrian conflict. This insurgence has resulted in a large proportion of youth who experience depression and other mental health disorders living in a country that has limited mental health care resources to provide care for these individuals.

To address adolescent depression in Jordan and other Arab countries, research-based data are needed to aid in planning effective strategies to implement primary prevention and treatment interventions. Unfortunately, research on adolescent depression within the Arab region is limited (Dardas, Bailey, & Simmons, 2016) and most research has focused on adult and geriatric populations (Al-Turkait & Ohaeri, 2010; Green, Broome, & Mirabella, 2006; Nasir & Al-Qutob, 2005; Sulaiman, Hamdan, Tamim, Mahmood, & Young, 2010). However, in a landmark series of quantitative studies addressing depression among Jordanian adolescents, one third of Jordanian adolescents ages 12 to 17 were found to experience symptoms of moderate to severe depression (Dardas, Silva, Smoski, Noonan, & Simmons, 2018a). The same authors studied the influence of depression and personal characteristics on personal and perceived depression stigmas (Dardas, Silva, Smoski, Noonan, & Simmons, 2017), characterized the depressive symptom profile, and examined gender differences in the type, severity, and correlations of depressive symptoms (Dardas, Silva, Smoski, Noonan, & Simmons, 2018b). The authors recommended additional research that focuses less on the metrics of outcomes and more on the qualitative processes that provide opportunities to glean authentic, rich, and meaningful insights on adolescent depression. Therefore, the authors designed the current qualitative study to reflect on the experiences of depression from Jordanian adolescents who report mild to moderate symptoms of depression. The current study aimed to capture adolescents' experiences of depression, identify perceived contributing factors, and assess their attitudes toward depression interventions.

Method

Design and Sampling

The current study received Institutional Review Board approval from the University of Jordan and Jordanian Ministry of Education (JMOE). The authors used an exploratory, qualitative design to collect focus group data from Jordanian adolescents who reported experiencing mild to moderate symptoms of depression. The current study was conducted in 12 Jordanian schools located in the suburban (n = 4), central (n = 5), and urban (n = 3) provinces of the country. The school setting was chosen because it is a critical environment for promoting adolescents' mental and emotional well-being and identifying those at risk for or experiencing mental health problems. For cultural reasons, these schools were homogenous in terms of sex (five male and seven female schools). However, the schools were heterogeneous in terms of socioeconomic and background characteristics, providing diverse views and experiences of depression.

Inclusion criteria were Jordanian male and female adolescents ages 14 to 17, who reported experiencing mild to moderate depressive symptoms, agreed to participate, and had parental consent. The selected age range was based on a previous study that revealed depressive symptoms are higher among Jordanian adolescents ages 14 to 17 (Dardas et al., 2018b). Adolescents with severe depressive symptoms or other psychiatric disorders (e.g., bipolar, conduct, substance use) were excluded. However, prospective participants who reported symptoms consistent with these other psychiatric disorders received proper medical referral instructions, and school administration was informed for follow-up purposes.

The Beck Depression Inventory (BDI-II) (Beck, Steer, & Brown, 1996), a 21-item instrument, was used to identify adolescents with mild to moderate levels of depression prior to enrollment in the focus group discussions. The BDI-II assesses a broad range of depressive symptoms (e.g., hopelessness, irritability, guilt, fatigue, weight loss), each of which is rated on a 4-point Likert scale ranging from 0 = minimal depression to 3 = severe depression. Total scores range from 0 to 63, with higher scores indicating greater depression. Score classifications are: 0 to 13 = no depression; 14 to 19 = mild depression; 20 to 28 = moderate depression; and ≥29 = severe depression (Beck et al., 1996).

Data Collection

The authors contacted the principals of eligible schools (n = 15) and provided them with full details on the current study's purpose, procedures, risks, and benefits. Three schools declined participation due to students' exam timetables. The authors made several visits to the schools to arrange for parental consents, adolescent assents, and depression screening procedures. Adolescents who met inclusion criteria were invited to take part in the focus group discussions between March and August 2018.

The composition of the focus group discussion was carefully considered to enhance the interaction among participants and thus the rigor of elicited data (Bruns & Grove, 2001) by achieving not only diversity, but more importantly, commonality. Homogenous groups are more likely to voice their views (Morgan, 1997), whereas heterogeneous groups have the potential of gaining a wide range of views (Ressel, Gualda, & Gonzales, 2002). In the current study, gender was considered a major issue when designing group discussions. Due to sociocultural considerations, and to avoid the confounding effect of gender on participant willingness to share perspectives on depression and its related factors, separate focus groups were conducted for male and female adolescents in their schools. Furthermore, based on other studies using focus groups, the focus group moderator was the same sex as the participants (Daley et al., 2010; Linden et al., 2007; Stillman et al., 2007).

Twelve focus group discussions with adolescents (five with male participants and seven with female participants) were conducted. No new ideas or experiences emerged in latter group discussions, confirming discussion saturation. All discussions were conducted in private, comfortable rooms within the school setting. Refreshments were offered to create a friendly and social environment. A semi-structured interview format was used incorporating open-ended questions:

  • When you hear the word depression, what is the first thing that comes to your mind?
  • What symptoms of depression do you think you have?
  • What do you think triggers these symptoms?
  • What do you often do when you experience these symptoms?
  • What would you consider the main sources of help or support for you when you feel depressed?
  • What do you think of available depression interventions? (This question was followed by specific probes on individual and group psychotherapies, psychopharmacology, and online programs).

The questions were developed from a preliminary analysis of two pilot group discussions as well as related literature on adolescent depression. During the interviews, probing questions were asked to elicit deeper responses on each discussion topic. Finally, issues emerging from earlier groups were used as prompts for discussion questions in subsequent groups. Interviewers collected field notes to document additional information, such as emotional content and nonverbal communication.

The format of focus group discussions followed a “funnel structure.” The first part was less structured to gain participants' overall perspectives. A “brain storming” technique was used to stimulate the discussion and interaction among participants (e.g., What comes to your mind when you hear the word depression? There is no wrong or right answer, no one will be individually asked). The style of moderating the discussion was low control and high process, yet moderators ensured that all relevant issues were covered in depth and all participants had the opportunity to speak (Bruns & Grove, 2001).

The discussion became more structured transitioning to the topic of interest (e.g., depression experience, risk and protective factors of depression, coping mechanisms with depression, acceptability of various treatment options, impact of spiritual and cultural values, and family and societal structure on the experience of depression). To end each discussion, the moderator provided participants with a verbal summary that synthesized significant themes, which participants subsequently confirmed (Barbour & Kitzinger, 1999). The average length of all focus group discussions was approximately 70 minutes. Two shorter group discussions included in the analysis lasted approximately 30 minutes and were used as complementary and conformability evidence of the other, longer focus groups.

Data Analysis

All focus group discussions were digitally recorded and transcribed verbatim by two bilingual translators with experience in health sciences. Two authors analyzed the data using NVivo version 11 software. A thematic analysis approach was used to enable the analysis of large quantities of participants' narratives. This approach involved an inductive analysis of participants' experiences, attitudes, beliefs, and behaviors to develop an overall picture of the experience of depression among Jordanian adolescents (Lambert & West, 2002). All transcripts were read several times to develop familiarity with the data. A line-by-line search of the transcripts was conducted to identify central themes (e.g., How do adolescents cope with depressive symptoms?). A category system was created for each transcript, and themes were connected to each category based on relevance. Categories were collapsed based on similar content (Burnard, 1991). Finally, each category was examined within the context of each question reported in the discussion schedule. The themes and categories were based on “real data,” which were double-checked by an independent qualitative researcher who generated a list of categories and then worked with the researcher (L.D.) to ensure a reliable categorization process. For unresolved disagreements, a third expert researcher (N.S.) was consulted to reach consensus.

Trustworthiness of Qualitative Data

The authors considered all elements of trustworthiness, including credibility, dependability, and transferability. It is argued that to enhance the credibility of qualitative data analysis, prolonged engagement with participants and their environment is needed (Bruns & Grove, 2001; Polit, Beck, & Hungler, 2001). In addition, before data collection took place, the moderators informally talked with potential participants to cultivate an in-depth understanding of culture and language, which in turn promoted trust and rapport with participants (Gillis & Jackson, 2002). The credibility of collected data was addressed by having participants confirm the consistency between their narratives and the summary of each discussion. Dependability was achieved by having an independent researcher re-categorize a random selection of focus group transcripts. The researchers (L.D., N.S.) discussed the agreement or disagreement of certain themes found in the transcripts. Finally, findings were examined to determine the extent of applicability of these themes to other participants (transferability). Although perspectives from adolescents may not be identical to those in the general population, there were some commonalities that might be relevant.

Results

Study Participants

A total of 92 participants were interviewed across 12 focus group discussions. Mean participant age was 15 years (range = 14 to 17 years). Participants came from all regions of Jordan. The majority (88%) had a good to excellent grade point average. Approximately one half of participants had at least one parent with secondary school education or less. Approximately 65% of participants had a household monthly income of <JD500 (US $705); 16% of participants reported having a chronic health problem; and 2% of participants reported a psychiatric diagnosis. Participants had a mean depression score of 21.5 (SD = 5.6; range = 13 to 28), indicating mild to moderate depression (Table 1 and Table 2).

Sample Characteristics (N = 92)

Table 1:

Sample Characteristics (N = 92)

Descriptive Analysis of Depressive Symptoms

Table 2:

Descriptive Analysis of Depressive Symptoms

Focus group expressions favored use of the passive voice or we/you pronouns. Adolescents rarely used “I” statements. In addition, gender differences in symptom expression were observed. More female participants reported seeking help than male participants. Female group discussions were on average 15 minutes longer and their individual answers were also longer compared to their male counterparts.

Thematic Analysis

The inductive analysis of different sets of emerging data from all focus group discussions (N = 12) uncovered two main analytical themes and related subthemes. The first theme focused on perceived mental health status as Being a Depressed Adolescent. This theme contained two related subthemes: Symptom Profiles and Feelings of Uncertainty and Perceived Roots of Depression. The second theme focused on the experience of Living With Depression and encapsulated two subthemes: Seeking Supportive Resources and Escape From Labeling (Table 3).

Thematic Analyses on the Experience of Depression Among Arab Adolescents (N = 92)

Table 3:

Thematic Analyses on the Experience of Depression Among Arab Adolescents (N = 92)

Theme One: Being a Depressed Adolescent

Subtheme One: Symptom Profiles and Feelings of Uncertainty. Early in each focus group discussion, participants were encouraged to discuss the meaning of depression from their own perspectives. Participants initially compared depression with sadness, raising the question of whether feeling depressed is more than being sad. Interviewers initiated probing questions to facilitate group discussions and reveal participants' perspectives. Using NVivo software, a concept search was used to confirm the commonality of a certain meaning. Each meaning was based on a participant's interpretation of depression and thus labeled as a “symptom.” Terms used to characterize their symptoms included: sadness (n = 61), anger and irritability (n = 56), hopelessness and pessimism (n = 43), crying for no reason, (n = 37), lack of interest (n = 27), difficulty focusing on school work (n = 27), thoughts of hurting oneself (n = 22), guilt (n = 17), loneliness (n = 12), and eating too much or too little (n = 9). These interpretations reflect their difficulty self-identifying their depression beyond symptomatology.

One recurring issue was participants' difficulty articulating and describing their feelings. Most participants were uncertain about the meaning of depression and how it relates to their feelings and experiences. However, the reported symptoms revealed some elements of depression: “feeling down,” “feeling frustrated,” “staying alone,” “feelings of emptiness.” These elements are exemplified below:

I have the symptoms the girls mentioned. But I am not sure. Not sure if this means I am depressed. But I am not like alone and crying. Maybe feeling down. Not sure.

Sometimes I feel like something inside me and want to take it out of my chest, but I can't. Sometimes I feel I want to cry but nothing comes out.

I couldn't continue doing things I used to do. Doctor, I would like to do something and then I change my mind and then I change my mind again. Why I feel different? It's frustrating.

When I'm with others sometimes I have this psychological situation where I just pretend to laugh. I just stare or stay alone. I don't know what you call this, but I am like always thinking but at the same time my mind is empty.

The uncertainty reflected in these excerpts suggests the lack of opportunities for adolescents to express and reflect on their experiences with depression. It should be noted that cognitive and physical symptoms of depression (e.g., difficulty concentrating, issues with sleeping and eating, irritability) were rarely discussed. However, when prompted, most participants reported experiencing many of these symptoms for prolonged periods of time.

Subtheme Two: Perceived Roots of Depression. The initial analysis revealed that participants' images of depression were linked to some perceived causes or roots. Further analysis grouped these causes of depression across three levels: individual, family, and school. At the individual level, most participants believed that a lack of faith in God and God's will predispose an individual to depression. Other perceived roots included bad experiences (e.g., death of a parent or sibling), having a weak personality, being a failure, being exposed to envy and Jinn (Arabian mythology: an intelligent spirit of lower rank than the angels, able to appear in human and animal forms and to possess humans), and not abiding by family's wishes.

When you don't trust Allah [God], you will feel pessimistic.

Depression may come without reason. Maybe because you are happy; people envy you. They make you lose happiness and power.

Everything I do is a chore and it needs so much effort because I don't have the will to do it, I keep telling myself that I will be a failure.

At the family level, adolescents reported that protective and autocratic parenting, lack of family communication and support, parents who experienced depression or other mental health issues, and poor family socioeconomics, were the causes of depression in their age group.

You feel suffocated. Your parents prevent you from doing something that your friends are always doing. Your friends go and play but your father would always object “do not go…do not go.” He is afraid that something would happen to you. He thinks this is for my own interest, but this is affecting my feelings.

Yesterday my father set up a rule; in order to take the phone, I need to finish my readings…. I hate this attitude.”

Money! When you want to go out and you need money...when all friends have the money and they can get everything they want, and you just look at them.

At the school level, most adolescents disclosed that their inability to fulfill school requirements and maintain high grades made them feel frustrated and depressed. Adolescents ages 15 to 16 reported tremendous pressure, depression, and fear of the Tawjihi exams. Tawjihi is the general secondary examination held in most Arab countries; students who fail the Tawjihi are not eligible to enroll in any university. Despite the perceived burden of school, some girls from impoverished families preferred school rather than staying home because staying home meant they had to contribute to their family's welfare by managing household responsibilities. Finally, participants believed that their teachers missed identifying their mental health needs. Teachers treated their problematic issues, such as lack of concentration or irritability, with discipline and punishment.

I started to lose my concentration. I cannot study, I know I have exam and I have to study but I just can't, and I start to cry and so on.

If I don't do well in Tawjihi then I will stay home. There is no chance to improve myself.

…I mean some teachers don't understand us; as if a stranger is talking to you. She just lectures you and leaves.

Right now, I'm in the 9th grade and my friends became in the 10th grade. I failed. I stayed in same grade. I hate my teachers.

No participants referred to biological factors (e.g., neurotransmitter changes, heritability) as components of depression. Some participants remained uncertain of the cause of their depression, assuming it happened with no connection to any event in their lives. Participants perceived the roots of depression were related to personal, family, and academic factors.

Theme Two: Living With Depression

Subtheme One: Seeking Supportive Services. Participants described ways they sought support for their depression. Most participants reported seeking help from close friends. Few participants reported talking to a favorite teacher or a relative. Participants seeking support from parents for their depression and related emotional issues was inconsistent. Some adolescents thought that parents contributed to their stress and emotional concerns, and thus did not believe their parents would help them overcome any stress or depressive problems. Male participants expressed concern about their fathers as the main source of stress and depression.

My mother is very loose and cooperative. But my father, oh! He makes home like a military barrack! I never say no to him!

Most female participants perceived their parents as a source of care and emotional support, giving them practical and financial help. Female participants affirmed their need to spend time with their parents, including sharing ideas and having fun. Parental judgements influenced female participants' perceived need for help. This was especially true for mothers, who seemed to determine when and where children received mental health services. However, not all female participants agreed that mothers were trustworthy sources of support.

Of course, the mother will help relieve the depression and stress and whatever the problem was, the mother will support her daughter.

[Interrupted by another girl in the session stating “That's not right.”] Not always. Mothers aren't always good but we don't dare to say it so people don't think we are bad daughters. You cannot trust them. They will tell fathers everything. [Other girls smiled and nodded]

As previously described, some participants believed that the lack of trust in Allah might lead to depressive symptoms. Thus, they found that praying, reading the Quran, and performing rituals, such as fasting or almsgiving, were valuable sources of emotional support, especially among girls. Boys more often cited playing video games when feeling down or stressed.

When I feel full of negativity and have no desire to contact people, I pray and read Quran. I tell Allah my wishes and mistakes and seek his help. Only he will not judge me. Allah knows people and knows who insulted [me] and he would take revenge on my behalf.

Although some adolescents were resourceful in finding support from people in their lives, others remained vulnerable to depression.

Subtheme Two: Escaping From Labeling. The fear of being called majnoon (i.e., crazy) was a significant barrier to reporting symptoms of depression and seeking help. Participants expressed concerns over being ashamed, misunderstood, or even estranged from their families and tribe if they showed or talked about their real emotions. Female participants reported fears that their communities would think they were bewitched, and this might exacerbate their depression and hurt them further. Few participants reported that depression is considered a dangerous and difficult to treat disease.

To assess participants' views on specific forms of treatment for depression, the authors asked the question: “What do you think of available depression interventions?” The authors followed this question with prompts for thoughts on individual and group psychotherapies, psychopharmacology, and online programs. Most participants (male and female) believed that individual psychotherapy with a same-sex professional is the best treatment for depression. They also cited that getting scientific, active, and tailored feedback in creative formats via professionals would be more effective than reading information. Many female participants reported they preferred for their parents to receive information on adolescent depression to help them manage their depressive symptoms.

I wish we could have an expert person to talk to her. Someone who can control the situation and explain to you what is going on with you. But all will ask for parents' permission. I don't want to tell anybody.

We do not need more homework to do! I do not want to just read.

Maybe if it includes entertaining videos or animated clips or some cartoons. I honestly don't understand big words [laughs].

Despite having positive attitudes toward psychotherapy, most participants reported they would avoid actively seeking such treatments, because they feared being labeled as mentally ill and evoking public, discriminatory responses against them. However, the idea of having an internet-based depression prevention and treatment program was an appealing idea for participants. They viewed the ability to receive treatment anonymously as a plausible alternative; however, some participants expressed genuine concern that parental oversight of their internet access (e.g., restriction and supervision, viewing browsing history) would inhibit their use of an internet-based program.

Once they feel you are focused on something on the phone, father or mother would come and sit beside you! They may suddenly grab the phone to see what you are looking at.

Discussion

Understanding adolescent depression is a complex and challenging task for families, health care providers, educators, and adolescents themselves. The purpose of the current exploratory qualitative study was to obtain perceptions about depression from Jordanian adolescents who might otherwise be reluctant to share their experiences. The current study has revealed important findings related to adolescents' experiences with depression, perceived contributing factors, and attitudes toward depression interventions. The impact of gender differences in recognition of symptoms, willingness to seek care, ability to communicate symptoms, expectations of care, and views on the best sources of help are also described.

Many participants reported the lack of opportunities for them to express and reflect on their experiences of depression. They also had difficulty articulating the meaning and experience of depression and were uncertain what symptoms are associated with depression. Consistent with previous studies of depression among Arab individuals (Al-Balhan, 2006; Obermeyer, Bott, & Sassine, 2015), cognitive and physical symptoms of depression were rarely discussed unless prompted by interviewers. These findings illustrate the difficulties adolescents have in discussing depression, despite recognition that these discussions are essential for early detection, diagnosis, and treatment. The 2015 WHO campaign, Depression: Let's Talk, is designed to engage adolescents and families into talking about depression and recognizes these conversations as a vital component of recovery. In addition, talking breaks down the stigma surrounding depression and leads to more people seeking help.

There is a need to raise awareness among depressed adolescents about depressive etiologies that are empirically supported to counter prevalent myths and misconceptions. Research suggests that holding certain beliefs about depression might impact the severity of depressive symptoms (Teachman, Wilson, & Komarovskaya, 2006; Wadian, 2013). Several participants in the current study believe weak will, witchcraft, Jinn, lack of belief in Allah, and exposure to envy as causes for depression. Perceptions relating depression to having a weak personality could increase the risk for psychological distress, increase feelings of low self-esteem and tendency for social isolation, and eventually worsen depressive symptoms (Ciftci, Jones, & Corrigan, 2012). There is also evidence that holding certain etiological beliefs about depression can determine the severity and type of stigma experienced by individuals with depression (Teachman et al., 2006; Wadian, 2013). For example, endorsement of religious beliefs may predict greater personal stigma (Teachman et al., 2006). On the contrary, Kvaale, Gottdiener, and Haslam (2013) argue that highlighting biogenetic explanations of depression might unintentionally trigger the belief that people with mental illness have low chances of recovery and increase social distancing. The various reasons adolescents in the current study believe to be causes of depression should be understood as dynamic and interrelated in a semantic network that gives meaning to depressive emotional states and help-seeking. Efforts are needed to design and test culturally competent educational programs that correct misinformation about the causes and symptoms of depression and contradict negative attitudes and beliefs with information. These efforts provide greater opportunity to help adolescents and their families understand the struggles associated with depression, find hope, seek treatment, and recover.

Importance of Family Care

The importance of including the family when addressing adolescent depression cannot be overemphasized (Dardas, 2019; Dardas, van de Water, & Simmons, 2018). Findings from the current study demonstrate that family, especially parents, play a vital role in adolescent depression. Many participants reported that their depressive symptoms were directly related to negative family functioning or having over-protective parents. Research findings support these views.

Dysfunctional parenting may limit children from developing appropriate autonomy and the ability to make decisions and learn effective coping skills, which can also contribute to depression risk (Donath, Graessel, Baier, Bleich, & Hillemacher, 2014; Nunes & Mota, 2017). This belief was held by adolescent males. Most female participants perceived their parents as a source of care and emotional support when feeling depressed. Participants' decision on when, where, and how to seek help for depression was contingent upon their parents' perceptions and views. These data suggest that any efforts to address depression among Arab adolescents would benefit from having the parents involved. Family-centered approaches may help increase family understanding and acceptance of mental illness and establish protective environments for adolescents to grow and thrive; this approach also aligns with the Arab culture. Contrary to the self-reliant and “individually centered” lifestyle in Western countries, social life in Arab culture is characterized by “situation-centeredness” in which loyalty to one's family takes precedence over individual needs and goals (Nydell, 2006).

Implications for Practice

The results of the current study indicated that adolescents had positive attitudes toward mental health professionals and service, yet they felt challenged to use these services. Lack of resources and fear of being labeled as mentally ill were the most common cited barriers. These findings indicate that the level of stigma that adolescents believed others in the community have (perceived stigma) is higher than the level of stigma held by the adolescents themselves (personal stigma). To address this issue, using the school setting for depression education, prevention, and intervention programs might be particularly promising for Arab adolescents. Schools have the potential to reach large numbers of adolescents with undiagnosed and undertreated depression. In addition, schools may provide a non-stigmatizing framework in which mental health services can be provided. The school setting is considered a critical environment for promoting adolescents' mental and emotional well-being as well as for identifying those at risk for or experiencing mental health problems (Jane-Llopis, Barry, Hosman, & Patel, 2005). Unfortunately, the current study's findings indicated that schools did not seem to have a significant role in helping adolescents understand or manage their depression. This is a significant deficit that could be remedied by leveraging the school nurse, a role that is virtually absent in schools within the Arab region. Studies of school nurses in Western countries have shown that they are vital to the health and academic performance of adolescents (Carnevale, 2011). School nurses can assess students who present with symptoms and determine their risk for depression. Adolescent depression can be difficult to detect and diagnose, because many adolescents with depression present with somatic complaints and the time for the consultation is limited. Thus, having a trained professional, such as a nurse, within the school is a promising intervention.

Conclusion

The results provide insight into Arab adolescents' understanding of the nature of depression, perceived contributing factors, and attitudes toward depression interventions. The fear of being labeled as mentally ill leads to poor engagement in, adherence to, and use of mental health services. The school setting might be a promising alternative and school nurses are an underused resource that may be leveraged to assess adolescents' risk for depression. Helping adolescents with depression is not a straightforward task, and future intervention research is necessary to determine what strategies have the greatest effectiveness in this vulnerable population. A comprehensive approach that considers Arab adolescents' beliefs, attitudes, and experiences in concert with the family and social context is needed to address the burden of adolescent depression in Arab nations.

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Sample Characteristics (N = 92)

Characteristicn (%)
Sex
  Female56 (61)
  Male36 (39)
Age (years)
  1410 (11)
  1522 (24)
  1628 (30)
  1732 (35)
Region of residence
  North19 (21)
  Center50 (54)
  South23 (25)
Grade point average
  90 to 100 (excellent)26 (30)
  80 to 89 (very good)25 (29)
  70 to 79 (good)25 (29)
  ≤69 (fair)11 (12)
Fathers' education
  Illiterate5 (6)
  Up to 11th grade12 (13)
  Tawjihia30 (34)
  Diplomab13 (14)
  University29 (33)
Mothers' education
  Illiterate5 (5.5)
  Up to 11th grade13 (14.5)
  Tawjihia27 (30)
  Diplomab17 (19)
  University28 (31)
Family monthly income (JD) (US)
  <150 ($211)2 (2)
  150 to 300 ($211 to $423)25 (28)
  301 to 500 ($424 to $705)31 (35)
  501 to 1,000 ($706 to $1,410)23 (26)
  >1,000 ($1,411)7 (9)
Has a chronic health problem14 (16)
Has a mental health problem5 (6)
Received a psychiatric diagnosis2 (2)
Has a parent with a mental illness2 (2)

Descriptive Analysis of Depressive Symptoms

BDI-II CharacteristicValue
Depression total scores
   N92
  Mean (SD)21.5 (5.6)
  Median24
  25th, 75th percentile16, 27
  Minimum, maximum13, 28
Depression severity categoryn (%)
  Mild35 (38)
  Moderate57 (62)

Thematic Analyses on the Experience of Depression Among Arab Adolescents (N = 92)

ThemeMeaning
Being a depressed adolescent

Feeling of uncertainty

Perceived roots of depression

Living with depression

Seeking supportive resources

Escaping from labeling

Authors

Dr. Dardas is Assistant Professor, School of Nursing, The University of Jordan, Amman, Jordan; Dr. Shoqirat is Associate Professor, Faculty of Nursing, Mutah University, Karak, Jordan; Dr. Abu-Hassan is Voluntary Assistant Professor, School of Public Health and Family Medicine, University of California San Diego, San Diego, California; Dr. Shanti is Founder and Medical Director, Omnia Pain Consultants, P.A., Phoenix, Arizona; Dr. Al-Khayat is Lecturer, Department of Educational Sciences, Salt Faculty, Al-Balqa University, Salt, Jordan; Dr. Allen is Director of Nursing Research & EBP, Duke University Health System, Durham, North Carolina; and Dr. Simmons is Professor and Chair, Department of Human Ecology, University of California Davis, Davis, California.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The current study was funded by the University of Jordan Deanship of Academic Research (grant 19/2018/1106).

Address correspondence to Latefa Ali Dardas, PhD, PMHN, CP, Assistant Professor, School of Nursing, The University of Jordan, Amman, 11942, Jordan; e-mail: l.dardas@ju.edu.jo.

Received: February 14, 2019
Accepted: April 23, 2019
Posted Online: June 12, 2019

10.3928/02793695-20190528-01

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