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Depression in Adolescence: From Qualitative Research to Measurement

Jonathan Lachal1,2,3,*, Mario Speranza2,3,4, Anne Schmitt2,3,5, Michel Spodenkiewicz2,3, Bruno Falissard2,3,6, Marie-Rose Moro1,2,3 and Anne Revah-Levy2,3,7

1AP-HP, Hôpital Cochin, Maison de Solenn, Paris, F-75004, France; 2INSERM, U-669 PSIGIAM, 97 boulevard de Port-Royal, Paris, F-75679, France; 3Univ. Paris-Sud, Univ. Paris-Descartes, Paris, F-75005, France; 4Centre Hospitalier de Versailles, Service de Pédopsychiatrie, Le Chesnay, F-78150, France; 5AP-HP, Hôpital Robert Debré, Department of Child and Adolescent Psychiatry, Paris, F-75019, France; 6AP-HP, Hôpital Paul Brousse, Département de santé publique, Villejuif, F-94804, France; 7Centre de Soins Psychothérapeutiques de Transition pour Adolescents, Hôpital d'Argenteuil, Argenteuil, F-95107, France

Abstract: Introduction: Depressive disorders among adolescents are public health challenges whether in terms of both morbidity and mortality. Because of the paucity of specific instruments to measure depression in adolescents, we undertook to design and develop a new tool, the ADRS (Adolescent Depression Rating Scale) using a qualitative and quantitative procedure. The psychometric properties of the ADRS have been already published in a previous paper (Revah-Levy, Birmaher, Gasquet, & Falissard, 2007). Goals: The aim of the present paper is to describe the results of the qualitative method we employed to build the scale which used in-depth interviews with 5 patients and 11 clinicians followed by a thematic analysis based on the principles of the Grounded Theory. Results: These research interviews yielded three aspects of the depressive experience: 1) Emotional state: irritability, the overwhelming nature of the depressive experience, negative perceptions of self and ideas of death; 2) non-emotional manifestations: mental slowing, sleep disturbances; 3) manifestations in social interactions: at work, in leisure activities, and in relationships. Using with three aspects of the depressive experience, a clinician version and a patient version of the scale were elaborated and submitted to a classical validation procedure leading to a final selection of 10 items for each (self and clinician) version of the instrument. Conclusions: This work supports the interest of using qualitative methods in psychiatric research to investigate the subjective experience of patients, which is a central dimension in clinical care.

Keywords: Adolescence, depression, measure, qualitative research.

OBJECTIVE AND SUBJECTIVE ASSESSMENT OF DEPRESSION IN ADOLESCENTS

The Usefulness of Developing a Scale Specific to Depres-sion in Adolescence

To implement therapeutic trials and evaluations of psychotherapeutic or medication-based therapies in adoles-cent populations, valid instruments are required. To date, most instruments have been chosen on the basis of a degree of popularity, despite absence of data for adolescent popula-tions, and despite the fact that they have not been adequately assessed in terms of validity and reliability. The instruments that are most frequently used among adolescents are the Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961); the Center for Epidemiological Studies-Depression Scale (CES-D) (Radloff, 1977); the Ham- ilton Depression Rating Scale (HDRS) (Hamilton, 1967); the Montgomery and Asberg Depression Rating Scale

*Address correspondence to this author at Inserm U669, Maison des Adolescents, 97 Boulevard de Port Royal, 75679 PARIS CEDEX 14, FRANCE; Tel: +33 614149002; Fax: +33 158412809; E-mail: jonathan.lachal@gmail.com

(MADRS) (Montgomery & Asberg, 1979); However the demonstration of their validity in this population is a topic of debate. Numerous authors have underlined the limitations of measures of depression in adolescents (Brooks & Kutcher, 2001; Myers & Winters, 2002). The criteria used in the psychometrics of adolescent depression are seriously criticised for the absence of hierarchy among the sympto-matic features screened for, and for the transfer of instruments used in adult psychiatry without any exploration of the specific features of the depressive experience in young subjects. These instruments have all been developed for adults, and have generally never been validated in adolescent populations, nor is there any sensitivity data for these popu-lations. To overcome these limitations, a specific effort has been made to develop more adolescent oriented measures of depression such as the Children’s Depression Inventory (CDI) (Kovacs, 1985); and the Reynolds Adolescent Depression Scale (RADS) (Reynolds, 2010). These instru-ments have shown interesting psychometric properties and have been extensively used in research (Osman, Gutierrez, Bagge, Fang, & Emmerich, 2010). How-ever, although interesting, these instruments have some limitations, mainly the reference to the DSM criteria for depression which are

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not developmentally based (apart from the irritability criteria) and do not explicitly include the subjective dimen-sion, which is central in the depressive experience, especially for adolescents. There is a real need for a valid and reliable diagnostic and measurement tool for depression in adolescents that could integrate its objective and subjective features.

It was in this context that we undertook the development and validation of a specific measure of adolescent depression (with both self and hetero versions) using an original methodology including a qualitative construction phase based on in-depth interviews with adolescents and adoles-cent psychiatrists.

This qualitative method aimed to describe, understand, and explore in depth, rather than to merely list observed phenomena. This qualitative method was based on a constructivist model, in which knowledge emerges from a human process of construction and reconstruction. Know-ledge of the phenomena is derived from a construction by the subject him/herself. The observed reality is co-constructed in a relationship of constant interdependence between the subject, the object, and the world (Mays, 2000). The qualitative method aims to describe a complex structure, and thence to derive a theory and produce hypotheses. The approach is inductive: the hypotheses emerge from the material, and from the context in which the reality is co-constructed by the subject and the researcher. This concept is known as the Grounded Theory (Glaser & Strauss, 1967). It is by analysing verbal material as it is obtained from observations and interviews that knowledge emerges. In medical research qualitative methods are expanding fast, in particular in the area of psychiatry where the place of the patient is central, both in diagnosis and in treatment (Brown & Lloyd, 2001).

It is therefore on the basis of adolescent narrative that we approached the adolescent depressive experience, seeking to apprehend their experience and identify its specific features and modes of expression, which necessarily involved in-depth consideration of nosographic and methodological issues.

The Present State of Qualitative Research on Adolescent Depression

Qualitative research aims to investigate subject view-points, their living experiences, and their interior world. This method is particularly well-suited to psychiatry, where patient experience is central in the care provided (Brown & Lloyd, 2001; Malterud, 2001). Yet, while there are plenty of studies on adolescent depression, providing a considerable amount of information, few studies have focused on adolescent discourse in order to approach the theoretical and therapeutic aspects of this mental disorder.

Between 1970 and 2005 only six qualitative studies investigated adolescent depression (Dundon, 2006). Accor-ding to results obtained from discourse collected from young subjects, it clearly appears that the adolescent depressive experience extends well outside the clinical definition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-TR (American Psychiatric Association, 2000),

despite the fact that similarities are observed between DSM criteria and descriptions provided by adolescents. Adoles-cents may consider themselves depressed, irrespective of whether they comply with the DSM category. Although the clinical symptoms reported by adolescents are varied and protean, most adolescents describe the feeling of losing touch with themselves, their families and their friends, as if they experience a sort of disconnection between themselves and their environment. The most frequently described feelings are anger, fatigue, poor self-esteem and pessimism.

In one study, adolescent patients hospitalised in psychiatric unit for different reasons were interviewed (Clarke, Cook, Coleman, & Smith, 2006). All of them described themselves as depressed, sad or having low morale. However the patients that were actually depressed described experiences such as "having to think about a lot of things", "being unable to sleep", "having to rely on others", "being a burden to others", "not getting better" and "being abandoned.” These results suggest that the most severe episodes of depression in hospital setting are experienced as a demora-lising experience. This demoralisation was characte-rised by the feeling of being unable to cope with a given situation, in particular a stressful situation, feelings of powerlessness and despair, accompanied by diminished self-esteem. Thus being demoralised appeared as the criterion that best characterised adolescent depression in a medical hospital environment.

Another study interviewing adolescents (Woodgate, 2006) highlighted the fact that being depressed is an experience of a very singular type, and that depressed adolescents, among other things, find themselves "living in the shadow of fear.” The study evidenced that the adolescents all experienced suffering on account of the illness. The main feelings were sadness, anger, fatigue and loneliness, which the adolescents lumped together in the category of "bad feelings", and which they saw as having a negative impact on their daily lives. These "bad feelings" were however not considered to be the only cause of distress, since the adolescents also reported experiencing fear when they could no longer control their depression. The study concluded that it was this aspect that led adolescents to realize the impact of the pathology on their daily lives. "Living in the shadow of fear" appears here as the aspect that is the most representative of what it means for adolescents to be living with depression.

These first studies suggested that the depressive experience in adolescence has specific features, and that it could be valuable to use narrative about this experience to develop a measurement scale specific to this population. It is this development that we propose to set out in this article.

The aim of this paper is to show how a qualitative met-hod, using in-depth interviews with patients and clinicians, can help building a specific tool to measure depression in adolescents. In this paper we sought to present the different qualitative steps (data collection, analysis of the overall descriptions of the experience of depression, selection of the specific items emerging from the verbatim, final construction of the tool) that allowed us to elaborate the Adolescent Depression Rating Scale, whose psychometric properties have been already published in a previous paper (Revah-

298 Adolescent Psychiatry, 2012, Vol. 2, No. 4 Lachal et al.

Levy et al., 2007, available at http://www.biomedce-ntral. com/1471-244X/7/2/).

THE QUALITATIVE PHASE IN THE DEVELOP-MENT OF THE SCALE

The development phase was in two stages: first a series of research interviews, on the one hand with five patients, and on the other with experienced clinicians (11 in all); second the construction procedure itself, building on the preceding operations.

The goal of this qualitative phase was to explore and describe the different aspects of the depressive experience in adolescence. The approach was phenomenological, involving detailed examination of the subject's life experience and his or her perception of an object or event. The phenomenolo-gical approach has been widely used to explore the experience of illness and disease (see for instance (Barr & McConkey, 2007; Senior, Smith, Michie, & Marteau, 2002; Taïeb et al., 2010)). It was used here not so much to subscribe to a particular conceptualization, or a diagnostic procedure based on preconceived ideas, but rather in non-restrictive manner, seeking to describe the facets of experience with the patients themselves so as to pinpoint the most prominent and specific elements. The interview stage as such required us to set aside our own representations of the depressive experience, our beliefs and our theories, so as to collect material that was as close as possible to the experience of our subjects, distancing ourselves from preconceived clinical and research positions and allowing the underlying themes to emerge (Glaser & Strauss, 1967).

THE ADOLESCENT INTERVIEWS: METHOD

We selected 5 patients aged from 14 to 17 seen in consultation in the child and adolescent psychiatry department in Avicenne Hospital (Bobigny, France) who agreed to take part in research "on adolescent emotions.” We did not know the patients. All the participants received explanations concerning the research, which aimed to jointly explore the painful experiences they had been through, asking them to describe it in their own words. In accordance with the Helsinki Declaration, written informed consent was obtained from the parents before the interview. This research was approved by the Ethical Review Committee (Comite d’évaluation de l’éthique des projets de recherche biomédicale (CEERB), GHU Nord), Paris, France).

These five patients were chosen for the diversity of their earlier clinical profiles, ranging from mild to severe

symptoms. They had all previously presented clinical depression, but the episode was over at the time of the inter-views. Subject characteristics are summed up in Table 1.

Data Collection

The interviews for this research were conducted in the department in a meeting room rather than a medical consultation office. Each interview lasted around one and a half hours. A semi-structured interview schedule was develo-ped to ensure that the different dimensions of the subjects' experience were broached, and the questions asked are given in Table 2.

The interviews were therefore long and thorough, and careful notes were taken on the details that emerged. All the interviews were recorded and the verbatim was transcribed. The verbatim transcripts and the recordings were compared, and the various stages in the analysis of the results were carefully documented. Finally a discussion was organized among the project experts to assess the relevance of the areas of experience that were described in the course of this procedure.

Data Analysis

A thematic qualitative analysis was conducted. The principles of Grounded Theory (Corbin & Strauss, 2008; Glaser & Strauss, 1967) were used to perform this analysis, including the identification of initial content elements (Zwaigenbaum, Szatmari, Boyle, & Offord, 1999). Then key words and phrases were organized into a preliminary model, with themes grouped under broad categories. Content analysis involved inductive and deductive techniques. Themes (Morse & Field, 1995) that emerged were compared in order to identify those that consistently emerged across case notes from all interviews. The steps of the analysis method are summed up in Table 3.

For each interview all the elements making up the description of the experience were collected, and words and sentences were extracted. From the initial inventory of "units" of experience, we detailed the different states described and the context in which these states occurred. The "units" were then grouped in themes, and then in larger ensembles with common features, and finally in general categories. Finally this produced a global description of the experience across the different facets of the experience, retaining detail on the content of the different facets.

Table 1. Adolescent Characteristics

Subject Gender Age Hospitalization Antidepressant treatment Psychotherapeutic treatment

1 Boy 15 Yes Yes Yes

2 Girl 14 No No Yes

3 Girl 16 Yes Yes Yes

4 Boy 17 Yes Yes Yes

5 Girl 16 No Yes Yes

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Table 2. Semi-structured Interview Grid for Adolescents

1. What do you remember about the time before you consulted??

2. Can you describe your feelings at the time? Can you describe your relations with your friends and your parents?

3. How were things in school, or in your work??

4. Did you realize something was happening to you??

5. How did you realize what was happening?

6. If you wanted to tell someone what it is like to be depressed, how would you put it?

7. Imagine one of your friends is depressed - what is it that would make you realize what is happening?

8. What are the words or phrases that would make you take notice?

Table 3. Steps inspired by Colaizzi Method

1. All the interviews are transcribed in verbatim.

2. The significant sentences are extracted; these are "units" that are directly connected to the experience described.

3. From this material, "units of experience" are derived

4. Thematic categories are then proposed for these units

5. The themes are grouped and organized to describe the experience.

To enhance validity, a single researcher carried out the main analysis, and transcripts were also read by two other researchers to improve consistency and coherence of analysis by ensuring that the themes identified were an accurate reflection of the data and that the analysis was not confined to one perspective. The results were discussed in repeated meetings with this research team. These discussions helped to highlight necessary clarifications or modifications among the themes identified. Another way of enhancing validity was also the care taken to distinguish clearly between what respondents said and researchers’ interpretations or account of it (Smith, 2008).

In the results below, extracts from respondents’ verbatim accounts have been chosen as exemplifying the underlying recurrent themes. In order to protect confidentiality, identifying information has been removed in the quotes presented. The verbatim account has been freely translated into English for the sole purposes of the present article, the main objective of the translation being to preserve the essential meaning and content, and as far as possible general tone. For greater clarity, certain words have been added in square brackets. Three dots represent a pause in the utterance.

THE ADOLESCENT INTERVIEWS: RESULTS

We noted that the experience "units" were generally organized in two different areas of the patient's life: the "inside" and the "outside" spheres. Across these main spheres we found three sub-categories: in the inside sphere an emotional category and a non-emotional category, and in

the outside sphere a category involving the interactions of the subject with the outside world and the quality of his/her investment in the outside world.

A Complex Emotional State

Irritability

Irritability is central in the emotional state of adolescents experiencing depression. It takes the form of marked reactivity in exchanges. It is not conflict that generates irritability, but rather a state of irritability that generates conflict with others (peers, family, teachers), so that relationships are stormy and exhausting. This irritability may be perceived by the subjects, or only by those around them. It may affect all areas of activity, or at first only show up at home. Irritable adolescents seem to find it difficult putting up with anything. They may not realize they are irritable, but describe bouts of anger towards people around them, and this gradually make relationships more and more difficult to sustain. Irritability was one of the main subjects in all the interviews, and the symptom that enabled subjects to measure the fluctuations of their own mental state. Stormy relationships were indeed noted by the adolescents themselves.

"I remember wondering why they were going on at me with their questions, everything they said made me sick, you know, like a battery inside me. I had no patience for talking to anyone.”

"They could see that could blow a fuse for nothing. My sister said it was like I was playing up or having tantrums, but it wasn't that, I felt as if everything was making me explode, well that's a bit strong... I don't know... I couldn't stop myself"

"To begin with, I could see that I was getting angry all the time, except with my girlfriend, but even with her I was shouting, everything got at me.”

The Overwhelming Depressive Experience

We were surprised from the outset by the absence of any spontaneous mention of sadness, with the exception of one girl who recalled sometimes "bursting into tears in the morning on the way to school.”

The adolescents talked about feelings of disquiet or malaise that they had difficulty actually pinpointing. These were states that caused people around them to say they were unhappy, depressed or miserable. It in fact appears that depressed adolescents cannot always identify what they are feeling. They do not spontaneously describe it as sadness, fear or dread, but what they do say is that they are afraid of losing control in the face of the overwhelmingly painful, unbearable feelings that they are experiencing. They talk of being bored, down in the dumps, saying there was "nothing in particular, I was really down, but I couldn't really say what it was.”

It is not depressive mood in general that is predominant in the adolescent discourse, but rather its overwhelming nature, swamping the subject in painful affects and thoughts he or she cannot control, and does not understand. The

300 Adolescent Psychiatry, 2012, Vol. 2, No. 4 Lachal et al.

subjects experience a disquieting strangeness, followed up by fear of these states that are engulfing them.

"It was unbearable, it would suddenly start to swell up, I felt overpowered, something really odd, it hurt, it sometime made me cry, but more than anything it hurt.”

"I remember when it started it was like I was stifling, not all at once, but like a weight on my chest, building up, until I couldn't bear it any more .”

“My grandmother could see I wasn't all right, I was really feeling bad, more and more, I couldn't hide it, I couldn't do anything about it. It's not easy to say how it was... My French teacher asked me if I was unhappy, it wasn't that, and at the same time it was, too, but it scared me that things were going that way"

Here we can see a progression: first fear of being overwhelmed, but the depressive experience is still contained - the subject feels threatened by the depressive experience, but it is not yet spilling over; then the feeling of being overtaken by the depressive experience; and finally, overwhelming, unbearable, invasive feelings that confront the subject with his or her inability to cope with what is happening.

Negative Perceptions of Self

These were expressed in a variety of ways. The subject felt he or she cannot live up to parental or school demands. He/she felt useless and incapable of doing or being, bogged down in negative views the life he/she is living and the things he/she does. This disqualification might be expressed verbally to the people around him/her, but most often the experience of depreciation took the form of incessant rumination that gets in the way of any form of activity.

'To begin with I tried to get on with my work even so, I really tried, but it was no use.”

"I felt so completely useless; it's a horrible feeling, everything about me made me look like a loser.”

"My friends did everything better than me, so I told myself, why bother trying"

"I could see I wasn't getting things done, my marks were useless, there was no way, I just couldn't do any better, I wasn't even trying any more"

Thoughts of Death

These were frequently mentioned, and sometimes were very serious. It was not so much the act, as desperate thoughts and scenarios that were prominent.

"I couldn't see the point in going on living, better to be dead... and when I actually do it, I won't make a secret, I'll tell everyone.”

"I couldn't see the way out of it all, I couldn't live with myself, I was afraid slipping, and when things were like that I was thinking that dying would put a

stop to it all, I couldn't see how it could stop other-wise."

For four of the respondents, suicide seemed the best escape.

"I didn't feel good physically, and I didn't feel good mentally...as if there was no place for me in normal life, it seemed to me it was better to be dead.”

Thoughts of death were mentioned when talking about times of great despondency and despair in the face of what is happening. Rather than actual suicidal acts, it is rumination about death and suicide that painfully overwhelm the subject. At times when the subject feels unbearably bogged down, an escape by death comes to mind. The themes of death and suicide are prominent in adolescence, and in the existential questionings that are common in that period. It is not these themes as such that belong to the depressive register, but the fact that the subjects' thoughts become overwhelmed by these themes. Death and suicide come to be seen as the only escape from the depressive suffering endured.

The experience of despair is never far off, even without any direct reference to death and suicide. There is a loss of meaning in day-to-day activities, in and out of school – something makes the subject feel that nothing is worth the effort, it is no use doing, working or living.

Non-Emotional Manifestations

Mental Slowing

This is not referred to as such, but it can be seen through disturbances in the train of thought. Thinking is described as slow, bogged down, disordered, making concentration increasingly difficult. It is naturally school work that is the most obviously affected, and reading activities. Everything appears as tedious and impossible to complete.

"I couldn't get to the end of my thoughts, I told the doctor that it was as if my head hurt.”

The consequences of this are in fact easier to describe than the actual alteration in the thought processes.

"I couldn't listen to the teacher for more than three minutes, I could tell that my ideas had stopped, as if they were somewhere else."

"I couldn't even watch TV, it was too much effort to listen and follow what was going on. That's not like me!"

Sleep

It is interesting to note that, in the adolescents' discourse, sleep is linked to the space of the bedroom, the adolescent's intimate sphere. Sleeping is not the only issue, it is rather being in bed, trying to sleep but not succeeding, not feeling rested, lying awake for hours in the bedroom. Four of the adolescents appeared excessively attached to in their beds: a place where there were no thoughts, no exchanges with the outside world, where they were alone within themselves, alone in the world, expecting nothing, thinking nothing. They generally said they slept badly, had nightmares, woke, or did

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not get to sleep. There is no particular sleep pattern. What is systematic is that sleep is poor quality and that the place of bed and the bedroom is central.

Manifestations Via Social Interaction

The adolescent is exposed via his/her relationships with the outside world – social, peer, family and school, and it was, unsurprisingly, in changes in relational constructions that the signs of depression can be detected. These manifestations appear in three areas of the adolescents' daily life, school, out-of-school activities and relationships. The "units" of experience observed in the interviews are as follows.

In School

The respondents reported obtaining increasingly poor marks in school, partly linked to difficulties understanding and concentrating, which in turn contributed to weariness and discouragement.

"I'd be sitting there for hours, and only get through two problems."

The lack of motivation to get work done and hand it in was another factor. Respondents were ashamed of the deterioration. They were aware of it, but felt they could do nothing to remedy it.

"I didn't want to work, I didn't want to go to school, I couldn't see what was the point any more; I was heading for a special [remedial] class because of all this crap, I didn't care ... it didn't matter."

Respondents knew that their parents were aware of the deterioration in their school achievements.

"And if they asked me if I'd done my homework, I'd say yes I had, but in fact I hadn't, I don't know why, I just wanted them to leave me alone.”

Another notable feature is the experience of the meaninglessness of school assignments - what was required of them was pointless, and their lack of incentive and implication led to deteriorating marks, a vicious circle from which they could not escape, also made worse by concentration difficulties. School in some cases became a place of punishment.

"Every morning it was a real fight to go there, I didn't expect any good from it, and anyway they'd get me cornered about everything, so what was the use."

"At the beginning the teachers seemed surprised, and then some of them got tough because I wasn't working, the atmosphere was really rotten, it quieted down when my father told them I was depressed... otherwise it would have been war...."

"One day my mother said, but you used to like school, what's the matter? I said I didn't know, but the truth is I didn't like it any more, I could only see all the things you have to do, not even my friends, I

had nothing but crap in my head, already full up with crap."

Leisure Activities

Respondents talked about enjoying things less and then not enjoying them at all. This loss of pleasure is accompanied by a degree of perplexity.

"Even I was surprised, I didn't know what else to say, just that I didn't want to, that's all, I don't know why but I didn't feel like it; normally speaking I really love basket-ball – I'm even very good at it."

The common features are feelings of discouragement, weariness, lack of incentive, complete loss of enjoyment, or a shift from enjoying something to feeling it has become too demanding.

"I dreaded Wednesday coming, I knew I had football, and I would have given anything to stay at home, I felt exhausted before I started, it wasn't something I enjoyed any more, it was punishment."

"Oh... my activities – I missed out without letting on about it; they weren't pleased, because I had chosen to do them, but I felt really awful there, I was completely fed up with it, I really didn't want to go any more, it's odd to say that you don't want a piece of the lovely cake you chose, but that was how it was, it didn't attract me at all, nothing did.”

Relationships

Three of the respondents talked about particularly painful manifestations in their relationships. During their depressive experience they felt they were different from others, isolated and withdrawn into their suffering, often choosing to be alone rather than with others; when they were with others their persistent, painful feelings of loneliness did not let up.

"People could have thought that I'd become a stay-at-home, I wanted to be home all the time, I could see that that things that happened made me feel alone, always alone, I can't really explain, I would have liked to say things to people, but I didn't know what to say, I was there in my own mess, that at least was clear, but I didn't know how to talk about it.”

"It seemed to me they couldn't see anything, I almost thought they didn't love me. I couldn't say a thing like that to them.”

Part of this feeling of loneliness was generated by the feeling of being different, and a resulting reluctance to show it to peers.

"If I could talk to them (friends) I would, but I felt I couldn't talk to them. They were always saying things like 'you're weird'"

"I had the idea that people were just putting up with me, even my friends"

"When you're depressed you feel you don't have anyone.”

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The experience of being alone with oneself, and the gap or mismatch between oneself and others, appear as invasive elements. What the respondents said suggested they felt they were losing touch with themselves or with others.

In fact two very different relational patterns were described. On the one hand, some adolescents were in a process of withdrawal and isolation from the outside world and from their relationships. On the other, some adolescents were struggling against the experience of collapse, exhibiting clinging relationships focusing on one particular object.

"For weeks I couldn't be without Melanie, I never let her go"

"When my mother got in from work I'd stay beside her, I don't know why, but it made me feel better"

"My father had a dog, it's funny, I didn't like him much, but I could see that at one time, I wanted him to be with me, even sleep with me, or go to school with me, and since then my mother has got herself a dog too.”

They expressed the need for a presence beside them, an attempt to have someone to hang on to in their struggle against unpleasant and painful feelings. What can be retained here are the two relational axes that emerge: withdrawal on the one hand, with its collapse component, and clinging behaviours getting the upper hand over isolation. Three of the respondents reported their friends to be numerous, and very necessary in the depressive period.

"I get on with most of my friends. I have quit a lot. They are generally the ones who notice when something's wrong. They talked to me about it, they could see that I wasn't OK. They'd suggest going somewhere to get me out of the house, so I'd tag along like glue”

Whether in school, in relationships or in leisure activities, the adolescents reported feeling weary and discouraged, unable to do things, emptied of their ability for enjoyment and their interest in life. They talked about constant, overpowering exhaustion, well beyond physical tiredness, making ordinary tasks difficult to complete.

"I didn't want to do anything all day. Even getting washed, I could feel myself dragging"

"I couldn't, I was doing just about nothing, I sometimes didn't do a thing all day, that's how it was, it was odd.”

Following this analysis, we can conclude that the depressive state in these adolescents can be described according to two dimension: interior and exterior. There are also three facets – one complex emotional facet including irritability, overwhelming by the depressive experience, ideas of death and negative self-perception; secondly a non-emotional facet including mental slowing, perceptible in concentration and sleep disturbances; and a thirdly facet including manifestations via social investment, school or leisure, and relationships in either withdrawn or in clinging mode.

Descriptive Elements That Were Not Retained In The Construction of the Scale

Several points need to be raised in this respect. The body appears in the issues of fatigue, sleep and a few somatic complaints, but we did not note any mention of eating disturbances, whether lack of appetite or snacking habits. Physical complaints were mentioned by two subjects, centered on school, with abdominal pain before leaving for school. These were not retained, since, as in the literature, we considered them to be too cross-sectional, and requiring more subtle analysis (Zwaigenbaum et al., 1999).

Ideas of death, on the other hand, appeared meaningful, alongside suicidal ideations, varying in relation to the degree of despair reported. No actual suicide attempt was reported. We did not retain suicide attempt in the scale, because the aim is not to measure risk of suicide, but to measure the intensity of depression. Suicide attempts are complex movements that articulate a depressive experience, under-lying anxiety, impulsiveness, isolation and recourse to action. Generally speaking, the question of the act of suicide in adolescence is a clinical issue that requires in-depth understanding of the processes of adolescence and of the conflict resolution inherent in these processes. We decided to avoid using suicide attempt as one of the experiences of depression, because it implicates other factors in adolescence.

We were not surprised to note the place of sleep as a sign of depression. However one particular aspect stood out in the interviews, and that was the predominance of nightmares. In their study on an adolescent general population, Kashani et al. (1989) noted that the item 'I have horrible dreams' was very significantly associated with depressive symptoms– withdrawal, suicidal ideas and pessimism–(Kashani, Rosenberg, & Reid, 1989).

Global Description of the Experience of Depression

For adolescents, experiencing depression is having to cope with a whole range of bewildering symptoms, emotions and changes in daily life. Subjects feel altered emotionally, and threatened by painful, overpowering emotions, which they do not fully understand.

The adolescents experiencing this state of mind feel different from others, severely isolated and withdrawn into themselves. They feel worthless, unable to take part in the business of daily living, whether in school or in their leisure activities. Despair can compound this state, and suggest a morbid outcome for the suffering. Thoughts of death and suicide become recurrent and insistent.

The weariness experienced is far more than mere physical tiredness, and entails a loss of motivation to get out and see friends, to get school work done, or to undertake anything. This aggravates the tendency to drop out of things, so that the experience of failing to get things done is even more painful. Thoughts are disordered, ineffectual and bogged down, and this is tiresome and distressing. Poor sleep means that exhaustion persists, and saps the ability to fight back against this weariness mingled with distress.

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School marks deteriorate, and this sustains the negative perceptions that subjects have of themselves.

Once depression recedes, the adolescent becomes aware of the positive changes because of the decrease in symptoms, the appearance of new abilities, the alleviation of feelings of anger, and the lessening of tension at home. The adolescent looks for ways to efficiently describe the experience, and tries to decipher what it was that made him or her depressive, recognizing that there are still unsolved problems.

RESEARCH INTERVIEWS WHITH PSYCHIATRI-STS: METHOD

Following this first phase with the adolescents, we undertook a series of interviews with psychiatrists so as to back up or confirm our observations (Table 4). Eleven clinicians were interviewed. The socio-demographic data is given in Table 5. They were chosen for the diversity of their approaches, both theoretical and clinical.

Table 4. Semi-structured Interview Grid for Clinicians

- Could you describe the different ways in which adolescent depression expresses itself?

- What do you think are the main clinical differences between depression in adolescents and depression in adults?

- What are the most telling symptoms for the measurement of depressive intensity?

- What words or phrases have you noted when adolescents describe their depressive experience?

- What is your opinion of the international classifications for depressive disorders applied to adolescents?

- What measures do you use in your clinical practice, and in your research on depressive disorders among adolescents? Have you remarks or criticisms to make about these scales?

RESEARCH INTERVIEWS WHITH PSYCHIATRI-STS: RESULTS

The Perspectives of French Clinicians

"The symptom profile I look for is more or less the same as for an adult – well, not really, because it's an adolescent I am seeing, but about the same.” The challenge is there: identifying and coping with this approximation, more or less the same, or more or less different.

We were not surprised to hear clinicians giving rather different accounts of the clinical characteristics of depression according their positions in relation to psychoanalytical

theoretical currents. On the one hand we had a clinical approach grounded in observation and understanding of the processes at work in adolescence, and on the other a descriptive clinical approach relatively cut off from any perspective on the processes of adolescence. For all the clinicians, the DSM criteria relate to a certain reality, but for the clinicians with a psychoanalytical orientation there is a degree of dissatisfaction with criteria-based approaches, which they consider do not account for the whole range of depressive states that they encounter.

In any event, for all the clinicians, whatever their orientation, depression does not completely fit the definitions proposed or even imposed by criteria-based systems. Clinicians diagnose depression in a complex, sometimes delicate alchemy, using a range of parameters—clinical, relational, family and school-related. These are placed in the perspective of their accumulated experience, which guides them in their day-to-day work of diagnosing depression in adolescents. This leads to a sort of compromise between the need to be aware of the standard criteria and the way they are used, and day-to-day practice that requires a more complex description—sometimes more confused in the minds of some—somewhere between a psychoanalytically-oriented approach and the DSM. One clinician quite openly said that he never used the DSM criteria, and that the sole issue was to detect subjects in a state of mental collapse that was not “within the reasonable limits of the normal processes of adolescence.”

Clinical Descriptions

The signs in adolescents reported by clinicians as those leading them to systematically look for depression vary from one practitioner to another. The signals used can be behavioural, school-related or thymic. Signs that are not specifically depressive lead to a diagnosis of comorbidity among clinicians using the DSM as a reference, while they are viewed as subsumed under depression among psychoana-lytically oriented clinicians. The latter indeed consider it inappropriate to use multiple diagnostic categories, such as behavioural or anxiety disorders.

Irritability and sadness were not the only emotions considered to be predominant. It was the overwhelming and invasive nature of the feelings that was emphasized by most clinicians, whether it was anger, emptiness, boredom, sadness or anxiety. It can also be noted that motor slowing was rarely considered by the clinicians interviewed as a sign of depression, and that physical signs such as somatic complaints were used cautiously because of their overlap with anxiety disorders. The clinicians were not in agreement concerning anxiety disorders, depending on their theoretical

Table 5. Clinician Characteristics

Clinicians Number Mean Age Hospital Practice Freelance Practice Teaching Research

Men 7 48 4 3 4 2

Women 4 45 2 2 3 2

Total 11 47 6 5 7 4

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orientations. Some considered that anxiety disorders should encourage diagnostic reconsideration, since they are very difficult to distinguish from depressive states. Others, independently from any consideration of underlying states, consider that these disorders are comorbid, and merely render diagnosis difficult.

From the interviews it also appeared that the use of categorical diagnostic criteria did not preclude a dimensional understanding in practice, a sort of implicit understanding that many clinicians naturally employed. The different facets of depression that we observed in the sample of patients were confirmed by the clinician interviews. It is indeed in the emotional and social space that depression is expressed. What emerges is a depressive state with modes of expression that are specific to adolescents and to their particular ways of being, both in the area of emotions, and in their relational and social involvement. The state of depressive collapse leads to a complex, painful, overpowering emotion, experienced as threatening and generating the fear of losing control. It should be noted that a number of the symptoms were described as non-significant when occurring in isolation, but as contributing to giving substance to the depressive state when associated with other signs, and also according to intensity. This is seen as particularly true for sleep disorders, for the different emotions, for self-perception, and for thoughts of death.

The clinicians were not fully familiar with the different instruments for measuring depression in research. They criticised them for their orientation towards adults, or for the lack of data on their performances among adolescents. However, despite this dissatisfaction, the tools were considered useful for what they are, that is to say tools for scientific research and communication, until more thorough studies become available concerning their validity in adolescent populations.

The Importance of the Diagnostic Process and the Clinician's Subjectivity

The interviews showed that the diagnostic process is complex, and articulates around the following: firstly semiological skills, which combine what the clinicians consider to be specific to adolescents with the "consensus" criteria for depression; secondly the theoretical orientation, which will have a considerable effect on the way in which semiological knowledge is handled; and finally clinical experience. In the encounter with the adolescent, these combined factors will give rise to a diagnostic hypothesis on the part of the clinician, which is also backed up by a general clinical impression. The hypothesis formed takes account of subjective elements in the encounter, the atmosphere of the encounter, and the quality of exchanges with the adolescent. These are signs that are not contained in inventories, but are highly useful indicators for the experienced clinician. Thus there are nosographic skills that can only exist within a subjective relationship. However the clinician will produce a diagnosis without really being able to provide any straightforward indications as to how it was actually reached. The perceptions used are not disordered or automatic, they constitute a genuinely clinical approach to the encounter itself, enabling the clinician to determine whether he or she

is dealing with a depressive subject. This involves the clinician's ability to empathize, and also to perceive his or her own counter-attitudes in the care relationship. This is essential, because the psychiatrist reaching decisions in terms of treatment is at the centre of the diagnostic process, and of the treatment proposal that will result from it.

Thus in this process the role of the psychiatrist cannot be dismissed in favour of the greater efficiency of screening criteria. Therapeutic efficacy is linked to the therapeutic alliance, which in turn is based on empathy and the quality of the encounter. A consultation is complex and interactive, a shared enterprise in which the clinical profile is not simply provided by the patient, but results from a co-construction in which the organizing role of the psychiatrist is decisive. The impact of the psychiatrist's subjectivity should not be minimized. The emotions of the psychiatrist are indeed often viewed as useful indicators in handling the care relationship. Adjustment, keeping the right distance, and taking account of the state of the patient throughout the care itinerary are considered essential. What we can add to this focus on the empathetic perceptions of the psychiatrist is the place occupied, without any doubt, by the clinician's empathetic perceptions in the diagnostic process itself. Semiology involves observation and listening oriented towards the patient, taking the focus away from the psychiatrist. Yet the clinicians interviewed widely underlined their various manners of apprehending the depressed patient, and of perceiving the emotional quality of the encounter, viewing these elements as valuable indicators that complement the screening for symptoms. There is thus a clinical dimension of empathy which appears to enable psychiatrists that are attentive to their own emotions to back up their diagnosis.

THE DRAFTING OF THE MEASURE

Following these two series of research interviews, we obtained a picture of the depressive experience comprising three facets: emotional, non-emotional and social. The content of these three facets is not radically different from that observed among adults, but the way in which it is expressed is very directly linked to the specific features of adolescents—the way they experience depressive emotions, and the signs observed in social, leisure, relational and school dimensions. Generally, these elements are considered to correspond to the effects of a depressive state, and they are used to measure the impact of the disorder on the subject's daily life. However they appear here as genuine symptoms of the depressive state as it appears to the adolescents themselves. The items were drafted according to the facets determined from the interviews, incorporating the content of each.

For the hetero-assessment, sets of items were drafted for each of the facets, and they were submitted to a group of expert clinicians. They were initially given a set of forty items covering the three facets of adolescent depressive experiences, and the subjective implication of the clinician in his or her diagnostic approach. The item wordings were reviewed and discussed—choice of words, expression of degrees of intensity—until a set of items obtaining a consensus was reached. The consensus method involved five adolescent psychiatrists working together. After three

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rounds, one group round and two individual rounds, agreement was reached on the items and the response scale (in terms of intensity) for the hetero-assessment. Eleven items were selected and reworded: irritability, overwhelming by the depressive experience, negative perceptions of self, thoughts of death, mental slowing, sleep disturbances, involvement in school work, involvement in leisure activities, withdrawal in relationships, clinging relations, and empathetic perceptions by the clinician. Each item is scored on four levels of intensity from 0 to 6 (0, 2, 4 or 6). The item scores can be summed to obtain a global score for the intensity of the depressive experience.

For the self-rated patient scale, a set of 150 items were drafted, using the patient verbatim, and the three facets of the experience described. From this universe of items the group of psychiatrists selected 44, and wordings were revised as appeared appropriate. The response format provides for yes/no answers. We first submitted the initial versions to targeted users; i.e. a few adolescents, who commented on readability and comprehensibility of the items in the self-report version, and the hetero-administered version was submitted to a few clinicians. This face-validity phase

produced two initial versions for use in the validation phase. The measure was called the "Adolescent Depression Rating Sale" (ADRS), in two versions, self and hetero-administered, referred to as ADRSp (patient) and ADRSc (clinician).

The detailed results of the validation phase have already been published (Revah-Levy et al., 2007), and will therefore not be detailed here. Following this first validation phase, ADRSc and ASRSp (Table 6, Table 7) showed good concurrent (Pearson correlation coefficients between the ADRS and the Hamilton Depression Rating Scale or the BDI ranged from 0.56 to 0.82, p < 0.05), discriminant (a sensitivity/specificity of 0.76/0.80 for the ADRSc and of 0.79/0.60 for the ADRSc) and factorial validity (with a stable two-factor solution in both versions), and good internal consistency (the Cronbach alpha coefficient was 0.79 for the ADRSp and 0.75 for the ADRSc for depressed adolescents) (Revah-Levy et al., 2011). The response pattern in the hetero-assessment tool is a Likert scale with four score levels, ranging from absent (0) to very severe (6). In the self-rating scale the responses are binary (yes/no). Information on practical aspects of use can be obtained from the author.

Table 6. ADRS Patient Version (ADRSp)

1 I have no energy for work/school ☐ True ☐ False

2 I have trouble thinking ☐ True ☐ False

3 I feel overwhelmed by sadness and listlessness ☐ True ☐ False

4 Nothing really interests or entertains me ☐ True ☐ False

5 What I do is useless ☐ True ☐ False

6 When I feel this way I wish I were dead ☐ True ☐ False

7 Everything annoys me ☐ True ☐ False

8 I feel downhearted and discouraged ☐ True ☐ False

9 I sleep badly ☐ True ☐ False

10 School/work doesn't interest me just now, I can't cope. ☐ True ☐ False

Table 7. ADRS Clinician Version (ADRSc)

Item Item Title Modality of Response Points

Absence of any irritability, either self-perceived or perceived by the observer 0

Irritability perceptible or felt in dealings with the subject, although he/she can control it 2

Considerable irritability in dealings with the subject, generating conflict, relational difficulties 4 1 Irritability

Intense, overpowering irritability making dealings and exchanges virtually impossible 6

No depressive feelings or thoughts (= gloominess, despair, sadness) 0

Depressive feelings or thoughts present but controlled and manageable 2

Feeling of being overwhelmed by depressive feelings or thoughts 4 2

Overwhelming experience of

depression

Intense feeling of being overwhelmed by depressive suffering that is devastating and impossible to contain 6

306 Adolescent Psychiatry, 2012, Vol. 2, No. 4 Lachal et al.

(Table. 7) contd….

Item Item Title Modality of Response Points

Perceptions of self are serene and relevant 0

Tendency to depreciation of self and accomplishments 2

Depreciation of self and accomplishments 4 3

Negative perceptions of self

Self viewed as completely worthless, useless, overpowering despair 6

No preoccupation regarding death or suicide 0

Occasional preoccupations regarding death or suicide 2

Recurrent preoccupations regarding death or suicide 4 4 Ideas of death

Pervasive and intrusive ideas regarding death or suicide 6

No sign of mental slowness, thought and speech fluid 0

Occasional difficulties in putting ideas together, mental inertia that hinders concentration 2

Considerable difficulty concentrating, obvious repercussions on daily life or school 4 5 Mental slowing

Massive mental inertia, that can result in concentration being impossible or the interview being difficult 6

No sleep disturbance, whether in duration or quality (= sleeplessness, nightmares, not feeling rested, sleeping excessively)

0

Occasional sleep disturbance, unusual to the subject 2

Marked, persistent sleep disturbance 4

6 Sleep

Major, persistent sleep disturbance, resistant insomnia 6

Sustained investment in school or professional activities 0

Loss of motivation for school or work, but activities maintained 2

Marked loss of motivation, disinterest for school or professional activities 4 7

Investment in school, work or job seeking

Total loss of motivation, complete disinterest for school or professional activities 6

Interest and enjoyment intact, good investment in usual non- school activities 0

Decrease of enjoyment or interest in usual non-school activities, but these are nonetheless maintained 2

Loss of enjoyment or interest, repeated absence from usual activities marked narrowing of activities 4 8

Investment in non-school activities

Absence of enjoyment or interest in non-school activities, total cessation of usual activities 6

No relational withdrawal 0

Unusual withdrawal from others 2

Relational withdrawal, isolation from others 4 9

Relationship withdrawal

Total isolation 6

Interview felt to have occurred in a serene atmosphere 0

Perception of sadness pervading the interview 2

Feeling there was over-riding emotion and/or irrepressible sadness 4 10

Perceived empathy from the clinician

Perception of intense silent distress 6

Intermediate responses are allowed from 0 to 6. CONCLUSIONS

In the absence of instruments specific to measuring depression in adolescents or validated for adolescent populations in French, we embarked upon the development

of a specific measure. The instrument produced is dimensional, and aims to detect conditions with few symptoms and conditions of intense depressive suffering alike. The interest of the ADRS compared to other

Depression in Adolescence Adolescent Psychiatry, 2012, Vol. 2, No. 4 307

instruments is to integrate in its construction methodology an in-depth analysis of the subjective experience of depression in adolescents. It is a validated, easy to manage, instrument with both self and clinician versions that can be used in clinical and research settings. In this paper we sought to show how a qualitative method, using in-depth interviews with patients and clinicians, can help building a specific tool to measure depression in adolescents Working on both the adolescent and clinician narratives has made it possible to distinguish specific aspects of the way depression is expressed by adolescents, enabling the development of an original tool better suited to clinical settings. ADRS is the first measure of depression entailing a qualitative construc-tion phase.

The ADRS thus appears to be a good tool to measure depression in adolescents; it is easy to use, and can be used in therapeutic research and more generally in clinical research, as well as for screening and epidemiological studies (Revah-Levy et al., 2011). Further studies are planned to explore other characteristics of the measure, such as the role of comorbidity, and to confirm these first very good validation results.

AUTHOR INFORMATION

Jonathan Lachal, M. D., is a child and adolescent psychiatrist at Maison des Adolescents, Department of Child and Adolescent Psychiatry, AP-HP, Hôpital Cochin, Paris, and a Research Fellow, INSERM - Université Paris-Sud, Université Paris Descartes, Paris, France.

Mario Speranza, M. D. Ph. D., is Head of the Develop-mental Disorders Unit, Department of Child and Adolescent Psychiatry, Centre Hospitalier de Versailles, and a Research Fellow at INSERM - Université Paris-Sud, Université Paris Descartes, Paris, France

Anne SCHMITT, M. D., is a child and adolescent psychiatrist at Developmental Disorders Unit, Hôpital Robert Debré, and Research Fellow, INSERM - Université Paris-Sud, Université Paris Descartes, Paris, France.

Michel SPODENKIEWICZ, M. D., is a child and adoles-cent psychiatrist at AP-HP, Paris, and Research Fellow, INSERM - Université Paris-Sud, Université Paris Descartes, Paris, France.

Bruno Falissard, M. D. Ph. D., is a child and adolescent psychiatrist, and professor in biostatistics at the Université Paris-Sud and Head of INSERM U669 research unit (Public Health in Mental Health)

Marie-Rose Moro, M. D. Ph. D., is a child and adolescent psychiatrist and Head, Maison des Adolescents, Department of Child and Adolescent Psychiatry, AP-HP, Hôpital Cochin, Paris, and Head of a research team, INSERM U669 - Université Paris-Sud, Université Paris Descartes, Paris, France.

Anne Revah-Levy, M. D. Ph. D., is Head, Centre de Soins Psychothérapeutiques de Transition pour Adolescents, Department of Child and Adolescent Psychiatry, Hôpital d'Argenteuil and Head of a research team, INSERM U669 -

Université Paris-Sud, Université Paris Descartes, Paris, France

CONFLICT OF INTEREST

The authors confirm that this article content has no conflicts of interest.

ACKNOWLEDGMENTS

We would like to thank the young patients who participa-ted in the research. We also thank A. Swaine Verdier for the translation work.

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Received: April 23, 2012 Revised: August 13, 2012 Accepted: August 14, 2012