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

Youth, Selfhood, and Antidepressants

Youth has long been viewed as an important period for the development of identity. Traditional theorists conceptualized this as an internally driven developmental stage focused on the making of a coherent identity. Erikson (1968), for example, situated “identity versus role confusion” as the predominant conflict between the ages of 12 and 19 although he did not see identity seeking as a finite process which was resolved during this period. In more recent years, youth researchers have challenged the idea of an absolute demarcation of adolescence and adulthood, recognizing instead that in contemporary societies there is an extension of some aspects of adolescence up to the mid-20s, sometimes called “emerging adulthood” (Tanner & Arnett, 2009). In this period, identity issues remain paramount for young people.

Although developmental theories still provide a framework for some researchers interested in youth identity, others have drawn from narrative theory to conceptualize identity as a more fluid product of the stories that people tell about their lives (McAdams, 1985). In this article, we use the concept of selfhood to describe the way that individuals make sense of their own identities through narratives (McAdams, 1985). From this perspective, people are seen as active in constructing their own identities through the stories they tell about themselves. At the same time, it is recognized that these stories are shaped (as well as constrained) by the cultural resources available to them (McAdams, 2011). These cultural resources are multiple and contradictory allowing for a range of different identity constructions that may be more or less salient for different individuals and social groups at different times (Bamberg, De Fina, & Schiffrin, 2011). These narrative identities have consequences for the way that people live and experience their lives.

Young people’s narratives of selfhood are shaped by contemporary cultural representations of youth and the contexts in which these are constructed (White & Wyn, 2013). Some of these influences include the pressure to develop an individually negotiated and self-actualized identity in spite of social conditions that make this difficult (Illouz, 2008). This is likely to be particularly challenging for women who experience a range of social adversities thought to explain their higher rates of depression (Nolen-Hoeksema, 2001; Ussher, 2010). What counts as self-actualization is also gendered. McRobbie (2007), for example, has argued that there is particular pressure on young women in a post-feminist era to live up to expectations that they should be successful and in control of their lives.

Young women are also developing selfhood in a time in which mental health problems are increasingly ascribed to a biochemical vulnerability. Rose (2003) used the concept of “neurochemical selves” to describe the way that, in recent times, understandings of distress have become inextricably linked to biology and argued that this helps to establish a boundary between what is considered normal and abnormal in society. Dominant discourses represent depression as a biochemical disease with references to this in online health information about depression and in advertisements for antidepressants (Metzl & Angel, 2004). Karp (1993) described how taking antidepressants reinforces a biochemical understanding of selfhood. As he puts it, “putting the first pill into one’s mouth begins both a revision of one’s biochemistry and one’s self” (p. 346).

Lafrance (2007) investigated women’s experiences of using antidepressants and noted that participants in her study welcomed a prescription of the medication as it legitimized their distress as a medical problem. She argued, however, that this interpretation ultimately provided “cold comfort” to the women, delegitimizing the real sources of their distress the social world (p. 135). The biomedicalization of distress is a salient issue for women whose emotion is often reduced to biology (Ussher, 2010). Young women’s distress, in particular, is often dismissed as “emotional volatility” associated with the biological changes of puberty (Sparks, 2002). This minimizes the unique demands on teenage girls, who are learning to navigate a social environment that requires much of young women while simultaneously being stressful and devaluing (Wiklund, Ohman, Bengs, & Malmgren-Olsson, 2014). Defining young women’s distress as an illness and treating it with medication has the potential to undermine the significance of their distress as a reasonable response to the challenges they face in society. On the contrary, Fullagar (2009), who provided a critical analysis of women’s experiences with antidepressants, noted that the medication also conjures up the compelling possibility of restoring “normality” for women who cannot live up to what society expects of them.

In addition, taking antidepressants has important consequences for people’s sense of agency and control over their lives. Fullagar (2009) argued that taking antidepressants to feel better might render women’s own efforts to improve their lives invisible. The authors have, in another article, not only described a process in which antidepressant use gave women a sense of agency in dealing with their distress but also noted how the biochemical model and longer term use of antidepressants undermined this agency (Cartwright, Gibson, & Read, 2018).

Researchers have highlighted other complex ways in which antidepressants can affect people’s selfhood. A range of studies have suggested that although people who used antidepressants felt that the medication helped with their symptoms, this often came at the cost of experiencing themselves as damaged or wounded (Metzl & Angel, 2004). Garfield, Smith, and Francis (2003) captured the paradoxical way that while antidepressants made some people feel better, this came with a sense inadequacy that they were needed in the first place. As they put it, this left the antidepressant user “returning to normal functioning while losing the sense of being normal” (p. 521). But while there is a substantial body of research on adults using antidepressants, there is less which explores how these issues might play out in relation to young people’s developing sense of self. One of the few available studies on young women’s experiences with antidepressants draws from interviews with 12 participants. This research suggests that young women might face a similar conflict between feeling better on antidepressants and struggling with the negative connotations of an illness identity (Knudsen, Hansen, & Eskildsen, 2003; Knudsen, Hansen, & Traulsen, 2002; Knudsen, Hansen, Traulsen, & Eskildsen, 2002). Knudsen, Hansen, and Traulsen (2002) also highlighted the impact of the stigma associated with using antidepressants, using the phrase “double stigma” to capture the experience of treating a stigmatizing problem (i.e., depression) with a stigmatized medication.

Although the existing research indicates that antidepressant use might have significant effects on young women’s developing sense of self, there has been surprisingly little attention paid to the significance of selfhood as a developmental issue for this age group. The current research aims to contribute to the limited body of knowledge about young women’s experiences of using antidepressants and to explore the significance of this for their developing selfhood. In this article, we address the question: “How do antidepressants shape selfhood in young women?”

Participants

Participants were recruited from a large pool of people that took part in an online survey on antidepressant use, which was widely advertised through the media in New Zealand (Read, Cartwright, & Gibson, 2014). Having completed the survey, potential participants registered their interest in taking part in a follow-up interview study. Sixteen participants aged between 18 and 25 years who had taken antidepressants for 6 months or more were included in this study. Thirteen participants were identified as New Zealand/European, whereas one identified as New Zealand/European and South African, one as Chinese, and one as Tongan/ Filipino. Eight of the participants were students, whereas the remaining participants were employed (in occupations that included counselor, nurse, teacher, youth worker, fundraiser, café worker, and office manager). Seven participants were taking antidepressants at the time of the interview, whereas the other eight participants had stopped taking them between 6 months and 2 years earlier. The length of time that participants had taken this medication ranged from 6 months to 8 years, and the average length of time was 3 years and 4 months. Seven participants had started taking antidepressants during their teenage years, and the majority of others in their very early twenties. We did not require participants to have had a formal diagnosis, but most identified with a label of depression although a small number also recognized anxiety as a part of their difficulties.

Data Gathering

All interviews were conducted by Celine Wills at a time and place convenient to the participant. Interviews lasted between three quarters of an hour and two and half hours. The interviews were digitally recorded and transcribed verbatim.

The interviews were conducted in a narrative style designed to prioritize the participants’ own accounts of their experiences with antidepressants (Riessman, 2008). The interviews began with the researcher asking participants to tell their story of how they began taking antidepressants. This usually elicited a response that lasted between 10 and 20 minutes, where the researcher’s responses were limited to non-verbal signals of attentive listening. Once the participant’s story had been elicited, the researcher asked the interviewee to go back to parts of their story to gain more information. Questions were generally open-ended and designed to encourage spontaneous descriptions of the participants’ own understandings the significance of the medication in their lives (Riessman, 2008). Given the depth and richness of the interviews, the sample size was considered sufficient for this analysis (Malterud, Siersma, & Guassora, 2016).

Understandably, talking about their experiences of taking antidepressants was an emotional experience for many participants. Some became tearful at different points during the interview. The researcher aimed to listen attentively, be validating and empathetic, and let the interviewees know that they could take a break should they need to. Despite this, all interviewees chose to complete their interview. The researcher checked with each of them at the end of the interview how they were feeling and offered a list of resources for support.

Data Analysis

Transcripts were analyzed using thematic analysis, which involves coding content around common themes (Braun & Clarke, 2006; Braun & Clarke, 2012). In the analysis described in this article, we focused specifically on the way that the participants represented their selfhood in relation to antidepressant use. Initially, the printed transcripts were read and reread to gain an overall understanding and familiarity of the text and to begin noticing patterns throughout the text. After this, transcripts were then analyzed line by line, and initial codes were generated. After coding all the data, we identified codes that related to selfhood and began a process of generating themes which related to the research question. All themes were then reviewed based on relevance to and inclusiveness of data, which involved combining some themes and discarding others. Data within each theme were discussed between the researchers to ensure appropriate fit and sufficient data inclusion. Once themes and subthemes had been established, one of the final stages was naming these themes, and defining them more clearly. This meant organizing the data in a coherent manner, analyzing, and writing a detailed account of each theme.

Trustworthiness was improved in this study by documenting each step of the research process in detail, including research design, methods, analysis, and conclusions, so that it could be open to scrutiny (Riessman, 2008). Reflexivity was fostered through on-going dialogue between the researchers about each transcript and its significance as well as the themes as these were developed. This also means that there is a high degree of transparency and that researchers could repeat this work, even if they do not necessarily get the same results (Shenton, 2004). Dependability was improved in this study through peer review. This was achieved through coresearchers and colleagues reading sections of the raw data to determine whether the findings were plausible based on the data.

A Diagnosed Self

Participants described how in the process of first being prescribed antidepressants, they came to understand their distress as a problem with a label. Some felt that it made their problems seem “more real” and that it meant acknowledging that they had difficulties. As one participant explained, “I felt like it was the end of the line, and I just had to acknowledge I had a real problem.”

Most were given a formal label of depression which they felt lent legitimacy to their experiences and demonstrated that their problems were “serious.” One participant explained that receiving her psychiatrist’s diagnosis made her feel like, “it’s not just like me making it up, it is actually as bad as I think it is kind of thing.” Other participants also conveyed that, without the medical diagnosis, their problems would not be taken seriously. As one young woman put it, “I was actually really worried that she would tell me that there was nothing wrong with me or something. So, it was a relief to hear actually it was depression.” In this way, being given a label and taking antidepressants eliminated questions in these young women’s minds about whether or not they were allowed to feel as they did.

A number of the participants recalled a history in which their distress had been downplayed or treated as an expected part of being an adolescent girl. One participant explained how her doctor responded to her disclosure of distress:

She just thought, I was a teenager at that time, it was just teenage thoughts and emotions and there’s nothing really to it, so she kind of downplayed it, which didn’t leave me in a good position because it’s just like wow, if it’s just nothing then why am I feeling this way and why am I feeling so hopeless.

The doubts that the young women expressed about being taken seriously also appear to have been internalized in the participants’ own self-understanding as the following quote suggests, “I think I just sort of saw it as just like being a teenager really and just being angsty and all that kind of stuff rather than this is like an issue, yeah.” In retrospect, she said that she felt that it was difficult for her to “figure out” that she was depressed because teenagers are “emotionally volatile anyway.”

Despite participants describing relief in response to receiving a diagnosis and an antidepressant prescription, this experience also led to negative changes in the way that they saw themselves. They used a range of words to describe how being diagnosed as having a problem made them feel, including “a failure,” “not coping,” “defeated,” “damaged,” and “not normal.” One participant elaborated on how receiving her first antidepressant prescription made her feel,

I felt like it kind of, it made me feel like different, it made me feel kind of like damaged almost . . . it just made me feel kind of like crazy almost, not crazy but like just different than other people.

For the young women in this study, accepting an antidepressant prescription countered ideas that they were “making up” their distress but also raised some significant challenges for their selfhood.

An Ill Self

Many of the participants used the language of physical illness to describe themselves during periods of distress, often referring to themselves as having been “unwell” or “sick” during these times Taking antidepressants seemed to confirm an illness identity as the following quote suggests, “You know the fact that you’re taking a pill was an indication that you’re really, really sick and you know so that’s sort of proof that you’re not coping and you’re sick.”

Although most participants seemed aware of the contribution of difficult life events to their distress, taking antidepressants seemed to necessitate at least a degree of acceptance of a biochemical view of their emotional experience. Participants sometimes seemed to be searching for a way to reconcile the impact of difficult circumstances with a biochemical view of the self as the following quote illustrates, “Well I know that what you experience in the outside world and your life can affect your brain and the way it works and everything that is happening in you.”

Most narratives suggested that there was comfort in accepting this view of their depression. One participant explained how in spite of having some uncertainty about the role of biochemistry in her depression, adopting this model brought legitimacy for her distress: “It meant that, it allowed me to justify to myself. I mean I don’t really know whether that whole biological model is true or not but it meant that I was able to justify it.” She elaborated the need for justification particularly in relation to other people’s social expectations adding, “[I can] justify it I guess to mum and to others too, that it was a biological thing.”

The overt or tacit acceptance of a biochemical basis for their distress also brought with it a range of challenges for the young women’s selfhood. Taking on a view that they had some kind of biochemical imbalance brought with it a sense of helplessness associated with an illness identity. One young woman, for example, talked about becoming “institutionalized” and said that it was possible to get stuck in the “sick role.” Several participants said that they felt that being on antidepressants underlined the fact that they could not “cope” on their own. One participant, for example, said that being on antidepressants made her feel “like I couldn’t manage my psychological issues myself without a pill.”

The implicit association between antidepressants and biological illness seemed to bring legitimacy to the young women who feared they might not otherwise be taken seriously but also positioned them as helpless and reliant on medication.

A Normal Self

Many of the participants in this study felt that their distress set them apart from others in their adolescence and early adulthood, and some alluded to antidepressants contributing to a sense of normality. One participant, for example, explained how “depression” had left her feeling “sad and tragic” through her teenage years. She explained how she had tried to hide her struggles from those around her and to pass for normal among her peers. When this failed it “sort of became that was who I was” and “what I built my identity around.” With many participants having experienced a disruption to selfhood during their teenage years, antidepressants seemed to bring the welcome possibility of being “normal.” One participant expressed it like this,

For me it makes me feel how I imagine how everyone else feels. I love it. Like I feel like I experience highs and lows and then, as any normal person would. I don’t feel like I am always low or drugged up on a high or anything like that, I just feel normal.

For some antidepressants also facilitated not only feeling better within themselves but also believing that their social functioning had improved. Several participants spoke about how antidepressants enabled them to “fit in” and find friends in a way that they had not previously been able to do:

But now I’m I guess like an average person which is good. Because I used to think myself as different from my friends and whatnot. But now I’ve got a few good friends. It’s good.

But while some narratives described a more normal self with antidepressants, other participants described how the appearance of “normality” brought with it what they experienced as a loss of self. One participant articulated how being on antidepressants made her feel as though she was no longer her authentic self. She described how she felt antidepressants had muted her “real self” which was “loud,” “impulsive,” and a “little bit crazy.” On antidepressants, she said, she lost interest in the things around her and in her relationships with friends. Other participants spoke about feeling “flat” or “numb” on antidepressants. One participant explained how she felt she lost something of herself on antidepressants:

And so I did notice just little things in my personality just weren’t there like um obviously caring about my friends which is a big thing and um just little things like I noticed once I’d come off them like singing along to music, like I stopped doing that and stuff. I just didn’t really exist I guess.

A few participants articulated the internal experience that antidepressants that although antidepressants had made them behave more “normally” it had made them feel strange and different:

Yeah it just kind of made me feel like I wasn’t quite normal anymore like it just kind of made me feel like it was a point of difference. Yeah, it just made me feel like weird, like I wasn’t normal. I don’t know how to describe it other than that, but like just different, yeah.

Participants’ accounts conveyed the value of finding a more functionally normal self on antidepressants but also losing a sense of a more vital, idiosyncratic self which for some, paradoxically, felt less normal.

A Stigmatized Self

Participants spoke about how taking antidepressants also produced a stigmatized self. A number of participants articulated their expectation that taking antidepressants would elicit judgments from others. Several said that they chose not to tell anyone that they were taking antidepressants. As one participant explained, “I just thought I can’t be bothered being judged for it.” Another suggested that that being on antidepressants made her feel that she owed everyone she spoke to an explanation “like an AA introduction.”

Although most of the young women in this study described having some support from close friends and family, these same communities were also the source of some of the more severe judgments that they received about their antidepressants use. One participant, for example, explained how her family who lived in a rural area would struggle to understand why she was using antidepressants. She imagined her mother saying “that’s [her] and she’s depressed and she probably takes drugs and stuff, you know.” She explained that when she tried to speak to her mother about it, she would change the subject.

Several other participants also described negative reactions from family members about them being on antidepressants. One participant explained that her mother “didn’t understand that [she] was sick and I needed them.” Another said that her mother said, “it was just like psycho mumbo jumbo and someone had just put the ideas in my head, because I presented as absolutely fine, you wouldn’t have known anything was wrong. So she didn’t necessarily believe it.”

Some young women felt that they had others in their lives who “meant well” and wanted to help, but did not understand what they were going through. One young woman talked about her grandmother trying to “cheer [her] up” by getting out travel books from the library for her, as this was something she usually enjoyed. She said of people in general that there can be “a lot of judgement,” and that people think “you can just cheer yourself up, but you can’t. You do need something beyond, even just a friendly face, you need something far beyond that to get out of it.” Similarly, another participant said she felt like her friends were trying to “fix her,” and would offer her advice, like “if you just get up and you put on your favorite t-shirt and you go out and you put a smile on your face and it will all be okay.” In these cases, friends and family were portrayed as not understanding how “serious” their difficulties were, and therefore, were not fully accepting of their illness identity.

In response to this, participants would turn to friends and family members who they felt understood them better. Some said that opening up about their experiences changed existing relationships in positive ways and contributed to them forming new relationships. One participant, for example, said of a work friend, “Yeah I had had a couple of breakdowns at work and so yeah she kind of needed to know what was happening, and once I had explained the whole situation, we became really good friends after that.”

Participants’ narratives suggested that they expected that their antidepressant use would be negatively judged by others. In close relationships, their primary concern was that their distress would not be taken seriously which led to judgments about their antidepressant use. Participants actively fended off stigma by, in some cases, hiding their antidepressant use and in others by seeking out people who would understand them.

An Uncertain Self

Participant accounts suggested that many were unsure about whether to attribute changes in their well-being to themselves or to the antidepressants that they were taking. Some of those, whose lives had improved after they began taking antidepressants, felt unsure whether it was antidepressants or other factors, such as lifestyle changes, that had made a positive difference. As one participant explained that “so much happened in that time, so it’s quite hard to tease out kind of the true effects if you like of the antidepressants.”

Participants not only had difficulty attributing positive change to antidepressants but they also could not decide whether negative experiences could best be attributed to antidepressants or to themselves and their difficulties. One participant, for example, articulated her difficulty in deciding whether her problems with memory and concentration were a feature of depression or a product of the antidepressants:

I used to be quite a sharp thinker and didn’t really have trouble writing anything and like since like about two years ago I just have like writer’s block . . . If it’s an effect of depression then it will go away if I’m feeling better but if it’s a side effect of medication that will mean it will be like this until I get off it or I have to change another one.

As participants experienced going on and off antidepressants at different times, this situation became even more confusing. One participant, for example, described going off antidepressants as being a difficult time in her life, but said that at that time, she was unaware that she may have been going through withdrawal from this medication and wondered if withdrawal contributed to this. Another participant similarly said that it took her a “couple of months” to figure out that the emotional numbing she was experiencing was the result of taking antidepressants and not just “her.”

Participants also experienced changes during the process of taking the same antidepressants, adding to the complexity of what changes in the self could attribute to the medication. Not only were participants confused about whether to attribute changes in their well-being to antidepressants or to something else, but they were also unclear about whether their emotional experience was being influenced by the antidepressants they were taking, or was in fact an expression of their “real selves.” As one participant put it, she wondered “Is what I’m feeling the drugs or is what I’m feeling me?” People also wondered who they would be once they stopped taking antidepressants. Another participant explained, “I guess I really don’t know who I’d be if I came off them. Like, I don’t know where my natural space is at anymore.”

Although some participants appeared to be actively engaged in a process of trying to work out who they were, this seemed more difficult for participants who had been on the medication for longer periods. One participant who had been on antidepressants for 6 years explained that she had given up on trying to make sense of her identity:

Over time I just stopped thinking about whether it was the drugs or whether it was me. After 6 years you’ve kind of got to give up on that question if it’s left unanswered . . . You’re just going to be like, well it’s not coming, so I’m going to stop trying . . .

This last quote highlights the impact of longer term antidepressant use on this participant. This was particularly relevant for a number of other participants who had spent most of their adolescent and early adulthood taking medication as the following participant graphically conveys,

No, I realized, like when I started, sort of after the year of going on and off medications and trying to keep track of different ones through the day or anything, I was just exhausted by it. It was stress in itself worrying about it all and I was quite hazy all the time, because I was sort of coming off one thing and onto the other and I couldn’t really remember why I had come off one or onto the other and I didn’t know what was normal anymore. So the baseline for am I better or not wasn’t clear. I didn’t know if I was improving or if it was making it worse because I couldn’t actually remember what it was like not being on medication.

Participants’ accounts conveyed the difficulty of constructing a coherent sense of self when they were unsure about whether what they were experiencing was because of the medication or other aspects of themselves or their lives. This was particularly difficult for those who could not have a clear sense of themselves prior to taking antidepressants.

A Powerless Self

Taking antidepressants brought the participants into a regular relationship with a health professional who prescribed the medication. Many of the participants had attended an initial medical appointment at the insistence of their parents, usually their mother. Although their parents were often described as being supportive, this meant that the young women were frequently positioned as children in their first interactions with a prescriber.

Although some participants described having been given good information and a choice about taking antidepressants, most felt pressured to some degree by their doctor or other adults in their lives. Participants conveyed the difficulty that young women might face in standing up to an adult health professional, who in some cases was also male. One participant described the doctor’s appointment which led to her being prescribed antidepressants as follows:

He was just pretty much like take them, don’t go home Google this, what it is or symptoms, just take them . . . So he said just take them, I don’t care what anyone else says, just take them. He was very forceful but in a nice way, not mean, but you just need to take them at this point.

Another participant explained how seeing her childhood doctor made it particularly difficult to speak out:

Well the thing with my doctor is she is my family doctor so I’ve been going since I was little but she’s the sort of person, it’s just like you need to do this, so do it. I didn’t actually know anything about the medication.

For young people, it seems that there was little attention paid to the usual practices of informed consent in health settings as this participant indicates: “I didn’t really get a choice over it. It was this is what you’re taking, do as you’re told type approach. It was no sort of informed decision making stuff.”

The participants, who were in many cases teenagers, felt themselves less knowledgeable or able to ask questions about antidepressant use than an adult might in similar circumstances.

Several of the young women also described how they had felt inconsequential in their busy doctors’ offices. One participant, for example, said she felt like “just another person on their list” and that “I felt like they weren’t like, they cared but they didn’t really remember who I was or like know who I was other than their notes.” Several others spoke about how having only brief appointments with their doctor, made them feel unimportant. Many also complained that there had been little follow-up from their doctors after the initial prescription

A few participants described how, over time, they had been increasingly able to assert themselves in appointments with their doctors and began to feel more “in control” of their medication use. One participant described how she had been able to refuse an additional medication suggested by her prescriber, explaining, “But if that was 10 years ago, I would have gone with it. Yeah, so at the time I was just doing whatever the doctor thought was best really and just hoping that would work.” However, overt assertiveness of this kind appeared rare in participants’ narratives and most of the young women opted to assert greater control in a covert manner, for example, by choosing to stop taking antidepressants without the input of their prescriber.

Participants described how their engagement with health professionals over antidepressants made them feel powerless and their distress, unimportant. Although some learnt to assert themselves more actively in these relationships over time, most experienced themselves as being subject to the power of the prescribing health professional.