Social Science & Medicine 57 (2003) 289–299

Problematising depression: young people, mental health andsuicidal behaviours

Sara Bennetta,*, Carolyn Coggana, Peter Adamsb

a Injury Prevention Research Centre, University of Auckland, Private Bag 92019, Auckland, New ZealandbApplied Behavioural Science, University of Auckland, Auckland, New Zealand

Abstract

The published literature provides strong evidence for connections between mental health issues, such as depression,

and suicidal behaviours. However, in spite of this, no investigations to date have explored young people’s perceptions of

the interconnections between depression, and suicidal behaviours. This article presents discussive analyses of

discussions of the contributions of depression to their suicidal behaviours of young people in New Zealand. Two

dominant discourses of depression emerged: a medicalised discourse, and a moral discourse. The medicalised discourse

was accessible to the majority of participants, and constructed depression as a disease. This discourse prioritised the

voices of health professionals and suggested that depression was difficult to resist. The moral discourse was an

alternative to the medicalised discourse, and constructed young people who experienced depression and suicidal

behaviours as failures. Both discourses were informed by a mechanistic cause-and-effect relationship between

depression and suicidal behaviours: attempting suicide was seen as an inevitable outcome of experiencing depression,

and suicidal behaviours were inevitably undertaken by young people who were depressed. Resistance to either of these

dominant discourses was problematic, and was best articulated during discussions of the stigma associated with mental

ill-health and depression.

r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Depression; Young people; Suicidal behaviours; New Zealand

Introduction

Public discussions of risk for young people’s suicidal

behaviours are often constituted by the primacy of

contributions from depression. For example, the New

Zealand Youth Suicide Prevention Strategy published

by the Ministries of Youth Affairs, Health and Maori

Affairs for dissemination to the general population

comments: ‘‘Around 90% of young people dying by

suicide or making suicide attempts are likely to have one

or more recognisable psychiatric disorders at the time’’

(Ministry of Youth Affairs Ministry of Health and Te

Puni Kokiri, 1998, p. 10). However, concern about the

effects of depression on young people’s suicidal beha-

viour and consequential health chances are not unique

to New Zealand. Internationally, there is general

agreement that depression (projected to be the leading

cause of disability and the second leading contributor to

the global burden of disease by 2020) among young

people is a significant contributor to the likelihood of

suicidal behaviours (World Health Organisation, 2000).

While acknowledging that the risk factors contribut-

ing to suicidal behaviours among young people are

complex and multifactorial, a review of the suicide

literature suggests a relatively uncomplicated relation-

ship between young people’s suicidal behaviours, and

depression. Epidemiological evidence strongly suggests

that mental disorders, such as depression, are major

contributors to the aetiology of suicidal behaviours

among young people (Beautrais, 2000; Brent, 1995;

Cantor & Neulinger, 2000; Gould & Kramer, 2001).

However, the role of depression in young people’s

suicidal behaviours is complex. Vajda and Steinbeck

(2000) suggest that the association between depression

*Corresponding author. Tel.: +64-9-3737-599x6151; fax:

+64-9-3737-503.

E-mail address: s.bennett@auckland.ac.nz (S. Bennett).

0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 3 4 7 - 7

and suicidal behaviours may be confounded, because

suicidal ideation is one of the diagnostic criteria for

depressive disorders. Additionally, while epidemiologi-

cal findings indicate a female preponderance in pre-

valence, incidence and morbidity risk of depressive

disorders (Piccinelli & Wilkinson, 2000), recent research

suggests that depression is likely to be significantly

under-diagnosed in men, such that men experiencing

major depression are much more likely to suicide

because they are consistently less able to access help

than their female counterparts (Blair-West & Mellsop,

2001).

The overwhelming majority of research investigating

the contribution of depression to young people’s suicidal

behaviours has been undertaken from an epidemiologi-

cal paradigm. Recently, Stoppard (2000) following

extensive searches of social science, health and psychol-

ogy data bases reported being unable to find any

research studies in which qualitative methods were used

to explore the depressive experiences of adolescent girls.

Comprehensive searches undertaken by the current

authors suggest a similar lack of research using

qualitative methods to explore experiences of young

men. Overall, the epidemiological literature indicates

that the role of mental health issues in young people’s

suicidal behaviours are supported by a ‘‘mechanistic’’

discourse. This discourse proposes an inevitable cause-

and-effect relationship between mental health issues

such as depression and suicidal behaviours. The core

arguments in the current epidemiological literature

propose a circular link between mental health issues

and suicidal behaviours: young people who undertake

suicidal behaviours are predominately experiencing

mental ill health, and suicidal behaviours are predomi-

nately undertaken by young people experiencing mental

ill health.

A review of the literature relating to young people and

depression suggests that this literature is also informed

and supported by dominant discourses of adolescence

which suggest that, in general (and irrespective of

suicidal behaviours), young people are pathological

and deviant. Social concerns about young people are

not a new phenomenon, and are supported by the

historical ‘‘truths’’ of young people as disadvantaged,

delinquent and deviant (France, 2000; Graber &

Brooks-Gunn, 1995; Heiman, 2001; Kelly, 2000; Swad-

ener & Lubeck, 1995). Recent literature suggests that,

although there may seem to be a greater number of life-

choices available to young people, pathways into

adulthood are becoming increasingly more problematic.

Consequently, contemporary youth-at-risk discourses

have shifted to encompass all young people. Summaris-

ing trends in policies and popular discourses around

adolescence, Heiman (2001) comments that practically

all young people have become pathologised and

suspect.

Connections between young people, pathology and

suicidal behaviours are also supported by the socio-

cultural construction of suicidal behaviours as indicative

of individual character failings or major flaws in moral

fibre. Attempting to end one’s own life is constructed as

an indication of failure to adequately cope with the trials

and tribulations of life events. In addition to being

constituted by discourses of moral failure, the moral

discourse of suicide is supported by the construction of

young people as significantly different to, and deviant

from adults. This is most clearly indicated by the ways in

which increasingly the period of adolescence and early

adulthood is seen as an inevitable ‘‘risk factor’’ for

widespread health and social problems, as if the origins

of these problems were innate to adolescents, rather

than ‘‘products of complex interactions of individual

biology, personality, cultural preference, political ex-

pediency and social dysfunction’’ (Hill & Fortenberry,

1992, p. 73). Dominant ideologies frequently applied

unproblematically to all adolescents are emotional

instability, propensity to sexual experimentation, risk-

taking, alcohol abuse, and involvement with illicit drugs

(Warwick & Aggleton, 1990). Development of the

concept of the ‘‘at-risk’’, or ‘‘high-risk’’ adolescent has

made the presence of ‘‘adolescence’’ and increasingly

early adulthood a marker for disease: a symptom of

illness (Hill & Fortenberry, 1992).

The research detailed here seeks to expand the current

epidemiological data by using discourse analysis to

explore the ways in which young people in New

Zealand, when discussing their suicidal behaviours,

engage with discourses of depression to justify and

explain their suicidal behaviours. Specifically, this article

presents findings from an empirical study focusing on

the experiences and perceptions of young people who

have attempted to end their own lives. The study is part

of an increasing body of literature which has developed

during the past decade offering critical considerations of

public health, and exploring health-related concerns

using discourse analysis. Discourses are ‘‘evolving

complexes of statements that reflect values, under-

standings or meanings specific to cultures, contexts

and times’’ (Towns & Adams, 2000, p. 558). Drawing on

disciplines such as critical social psychology and

sociology, discourse analysis has been used to explore

cervical cancer (Braun & Gavey, 1998); intimate partner

violence (Towns & Adams, 2000); rape and sexual

coercion (Gavey, 1990); and safer sexual practices

(Gavey & McPhillips, 1999). However, with the excep-

tion of one paper investigating suicide notes (McClel-

land, Reicher, & Booth, 2000), there has not been any

discursive research focusing on suicidal behaviours.

This article aims to highlight the complexities evident

in young people’s engagement with discourses of

depression and mental ill-health which constitute a

dominant part of the construction of young people’s

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299290

suicidal behaviour. Specifically, the analysis presented

here aims to examine the ways in which young people

negotiate and renegotiate relationships with dominant

constructions of mental ill-health which combine youth,

suicidal behaviours, deviance and psychopathology.

Methods: participants and process of analysis

The material for this analysis comes from in-depth

interviews with 30 young people who had attempted to

end their own lives. All participants self-identified as

New Zealand European/Pakeha; and had presented with

suicide attempt, including an overdose, self-inflicted

lacerations or self-inflicted injury by other means to a

public hospital Emergency Department in the Auckland

region. Previous authors suggest that mental illness is

more prevalent among young people who undertake

multiple suicide attempts (Vajda & Steinbeck, 2000).

Consequently, in order to investigate how young people

initially connect with the dominant discourses of suicide

and mental health, participants were limited to those

who had no previous record of deliberate self-harm.

Prior to participating in the interview phase, all

participants had been assessed by members of the

Psychiatric Liaison teams at the participating hospitals

as deliberately attempting to end their own lives. The

study commenced in 1999 following approval from the

New Zealand Ministry of Health Ethics committee.

Potential participants were initially contacted by a

clinical member of the research team, to invite them to

take part in the interview process and were interviewed

within a 2-week period of their presentation to an

Emergency Department following a suicide attempt.

Indepth semi-structured interviews lasting 1–2 h were

undertaken at a venue of the participant’s choice,

including homes, parks, cars and University offices.

All interviews were audiotaped and fully transcribed.

Participants came from a variety of backgrounds.

However, the majority would be classified as middle

class. The occupations of the female participants

included: tertiary and secondary school students; par-

ents; health care workers; administrators and catering

industry workers. Some were unemployed at the time of

their suicide attempt. At the time of the attempt, 12 of

the women participants were living with their parents;

six were living in a heterosexual partnership (e.g.,

defacto relationship); and five were living with flatmates.

Sixteen women were aged less than 20 years; seven were

aged 21–25 years. The majority of female participants

attempted to end their own lives by overdosing; five

attempted suicide by cutting their wrists.

The occupations of the male participants included:

tertiary and secondary school students; a banker; a

storeworker and a mechanic. Some were unemployed at

the time of their attempt. Two of the male participants

were aged 21–25; the remainder were 20 or younger. At

the time of the attempt, four of the male participants

were living with their parents; two were living with

flatmates, and one was living with his wife and extended

family. Two of the male participants attempted suicide

by drug overdose; one by hanging; one by cutting his

throat; and two men attempted to end their own lives by

gassing themselves in their cars. One male participant

combined an overdose with cutting his wrists in his

suicide attempt.

During the course of the interview process, all

participants were asked to consider aspects which they

felt had contributed to their suicidal behaviours. The

young people indicated that suicidal behaviours most

often occurred following a stressful event, such as

relationship difficulties (with parents or partners);

financial difficulties, drug and alcohol misuse or

seemingly insurmountable personal problems at school,

University or in the workplace. Others suggested that

precipitating events included overwhelming feelings of

sadness and uselessness following, e.g., the death of

someone close to them. The interview offered young

people the opportunity to discuss the events leading up

to their suicide attempt, and the events immediately

following it. Many participants also spontaneously used

this opportunity to discuss the interconnections between

mental health factors such as depression, and their

suicidal behaviours. Sometimes during the interview

process a direct question, such as ‘‘do you think you

were depressed?’’ was asked if an indirect reference to

depression was made.

For this analysis, multiple readings of the transcripts

were undertaken to find passages of discourse in which

the participants accounted for the contribution of

depression and mental ill-health concerns to their

suicidal behaviours. The analysis of the transcripts paid

careful attention to emerging patterns of meaning across

transcripts, but also to inconsistencies, ambiguities and

contradictions both within and between the interview

texts (Potter & Wetherell, 1987). Particular pieces of

transcript have been selected for presentation and

analysis because they illustrate broad thematic patterns

observed across many interview transcripts, or they are

an example of ‘‘potentially meaningful ambiguity and

contradiction’’ (McPhillips, Braun, & Gavey, 2001, p.

232), or both. Where necessary, quotes from interviews

with participants have been slightly amended to enable

the spoken word to be more easily read.

Depression as disease: a medicalised discourse

Summarising the literature relating to contemporary

theories of depression, Stoppard (2000) suggests that

recent models of depression in adolescence are compre-

hensive, and draw upon a combination of psychological

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299 291

(e.g., personality traits), biological (e.g., hormonal), and

social (e.g., peer pressure) influences and their interac-

tions to explain depression. Such models are ‘‘in line

with the recent shift in mainstream research toward

multifactorial, biopsychosocial models of depression’’

(Stoppard, 2000, p. 114). This professional understand-

ing of depression offered by Stoppard is congruent with

the ‘‘medicalised’’ discourse of depression which parti-

cipants utilised to locate the roles of depression in their

accounts of their suicidal behaviours. The medicalised

discourse of depression was constituted by the prior-

itisation of the voices of mental health professionals,

which constructed depression as a disease requiring

specialised diagnosis and treatment. Similar to the all-

encompassing influences on depression articulated by

Stoppard, the medicalised depression discourse indi-

cated that depression was difficult to resist, and that

suicidal or self-harming behaviours were inevitable

following recognition of depression. This discursive

construction of depression as powerful and all-encom-

passing also had implications for reducing the agency of

young people who identified as depressed. Within the

medicalised discourse, depression is constructed as

something which is solid, tangible and decontextualised.

That is, it is no longer a verb requiring an explanatory

phrase (e.g., John is depressed because he has lost his

job); depression becomes a noun: John has depression

(Adams, 1981).

Overall, the medicalised depression discourse was a

cultural resource available to the majority of partici-

pants. For many young people, the orthodox power of

the medicalised depression discourse was evident in the

way in which it provided a means of explaining suicidal

behaviours. For example, although Gina began her

account of her suicidal behaviours by suggesting that her

decision to end her life resulted from a relationship

crisis, she went on to suggest that the ultimate

contributing factor to her suicidal behaviours was

unrecognised depression. In the following extract,

reflecting on the contribution of depression to her

suicidal behaviours, Gina draws upon a medicalised

construction of depression to clarify her experiences:

I wasn’t doing well at school and I was doing things I

didn’t want to do. I was going out to parties and

drinking and stuff. It wasn’t really making me happy

and you know. I just thought, well as soon as this

year’s over it’ll be fine you know and I’ll come out of

it. I guess I didn’t really acknowledge that I was

feeling very down. It was just like a general lull. Just a

flat all the time which is depression but I didn’t think

about it. I knew that I wasn’t myself and I knew that

I was flat but I guess I kind of just pushed it to the

back of my mind. I didn’t recognise it as depression

until afterwards and people at the (community

mental health) service said, well that’s depression,

that general flatness.

Reflecting on events in her life before her suicide

attempt, at the beginning of her narrative Gina is

initially somewhat tentative about describing herself as

depressed. In spite of this tentativeness, she describes her

feelings at the time as variously ‘‘feeling very down’’, a

‘‘general lull’’, and articulates a series of events which

indicate her dissatisfaction with various aspects of her

life, including her social life and school life. Gina’s

appropriation of the medicalised depression discourse is

signalled by her acknowledgement of the ‘‘appropriate’’

meaning of her feelings: ‘‘Just a flat all the time which is

depression but I didn’t think about it’’. Gina also

positions herself as lacking in self-awareness when she

fails to appropriately recognise her experiences as being

indicative of depression. She indicates that she was

aware that she ‘‘wasn’t herself’’, and knew she was ‘‘flat’’

but did not adequately address these issues: ‘‘I guess I

kind of pushed it to the back of my mind’’. Her attempts

at self-management of her emotions and feelings were

not successful, congruent with the lack of individual

agency which characterises the medicalisation depres-

sion discourse. In her narrative, Gina suggests that her

interactions with experts at community mental health

services provided her with the clarity of vision to

understand and reframe her experiences and emotions

to explain her suicidal behaviour in a manner which is

congruent with the medicalised discourse.

Similar to Gina, Jack initially suggested that his

suicidal behaviour was a result of the culmination of his

inability to cope with mounting personal debts, and grief

following the death of a family member. However, Jack

also signals his positioning within a medicalised

discourse of depression from the beginning of his

narrative by aligning his experiences with the opinions

of various mental health professionals. In the following

extract, Jack provides a retrospective account of the

development of his sense of depression leading up to his

suicide attempt.

I sort of had an hour and a half session with a

psychologist at (community mental health service)

and also spoke to a psychiatrist as well. At the

moment I’m undergoing sessions at [mental health

service] House. I think the depression was just

something that you sort of go through—it just

becomes a habit. You start to believe that you’re

no good. You start to believe that sort of nothing’s

worth living anymore and everything’s hopeless and

so forth and it just, it’s amazing. I would assume that

about 80% of people that are in the same position as

I’m in would find that a lot of time they’re in a state

of depression. They would actually have no idea of

why they’re actually depressed. I mean there are

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299292

some people that do, for example, rape cases or

things like that. But in my position—worry and sort

of stress about things and debts of the family—after a

while that becomes numb and you just start to go off

on your own depression track and you’re naturally

depressed at the time. There’s a lot of anger and

sweating and all that kind of stuff, irritation and all

that. It’s quite a heavy road.

For Jack, positioning himself within the medicalised

discourse appears to offer the means of normalising,

naturalising and explaining his experiences of suicidal

behaviour. In his narrative Jack constructs an account

of the aetiology of depression which draws upon the

expert voices within the professional depression dis-

course. He suggests that depression may occur following

‘‘worry and sort of stress about things’’ (as was his

experience), or may occur following a traumatic

experience ‘‘rape cases or things like that’’, or may also

occur for no apparent reason: some people ‘‘have no

idea of why they’re actually depressed’’. With his

assertion that ‘‘about 80% of people that are in the

same position as I’m in would find that a lot of time

they’re in a depression, a state of depression’’ Jack

utilises the professional voice of statistics in an

endeavour to locate his experience of depression as

one which is normal, that is, it is an experience shared by

many others in the wider community.

Positioning himself within a medicalised depression

discourse has implications for Jack’s sense of agency. In

his account, Jack constructs himself as experiencing

limited agency to disrupt this relationship. For example,

depression is constructed as a disease which has to be

passively endured ‘‘it was just something you sort of go

through’’, and is also out of his control ‘‘it just becomes

a habit’’. Consequently, it is natural and inevitable

therefore to believe ‘‘nothing’s worth living anymore’’

and ‘‘everything’s hopeless’’. In this account, Jack

articulates a mechanistic explanation of the contribution

of depression to suicidal behaviours. He constructs his

experience of depression as part of a linear, inevitable

and natural pathway towards suicidal behaviours.

According to Jack the ‘‘depression track’’ begins with

stress and worry, and progresses to be ‘‘quite a heavy

road’’. Consistent with the medicalised depression

discourse constituted by limited personal agency Jack

suggests that departing from this pre-ordained pathway

is difficult, unless one follows the appropriate medical

treatment options.

Being positioned within the medicalised depression

discourse has consequences for the treatment of depres-

sion. In the above extract, Jack articulates a variety of

depression treatment practices which are congruent with

the professional depression discourse, including sessions

with mental health professionals, and group therapy.

These treatment practices also mediate individual

agency. The social structures of mental health care

practices suggest that the power for ‘‘curing’’ mental

illness remains with the health professional, while the

recipient of the cure is required to respond in appro-

priate ways to facilitate the optimum outcome (e.g., to

attend organised therapy sessions).

Talk of depression ‘‘exists in a matrix of other

discourses and institutional relations’’ (Harper, 1999,

p. 127), including relationships with anti-depressant

medication. Anti-depressant medication is one aspect of

the medicalised depression discourse, in that such

medications are signifiers of the appropriate treatment

of the disease of depression, authorised by a legitimate

mental health professional such as a psychiatrist. For

young people who aligned themselves within the

medicalised discourse, talk of anti-depressant medica-

tion was frequently characterised by a sense of safety

and healing, which decreased the likelihood of suicidal

behaviours. Conversely, ceasing to take medication is

associated with increased risk and danger. Louise had

initially been prescribed anti-depressant medication

following the diagnosis of an eating disorder. In the

following extract, Louise discusses what occurred when

she took away her Prozac safety net:

The other thing that happened is I’d just come off

medication. I’d been on Prozac for four years, three

years and I was cutting down. I was on 60mg and I

cut down to 40 for a week and then I just took myself

off it completely and that made a major difference

like that it just became the real me—the real

depressive. It made a major difference. Had I not

come off the Prozac I think it might have been quite

different, because I don’t know that I would have

actually gone through with it (attempting to end her

own life). I think I would have still thought about it

heaps but I don’t know that I would have gone

through with it. Now I’m back on Prozac and I’m

back to my old self which is completely fine again.

In the above extract, Louise contrasts between a

constructed identity as ‘‘the real me—the real depres-

sive’’ and an alternative identity as a self-on-Prozac. By

emphasising her personal safety while on Prozac, Louise

aligns herself with the medicalised depression discourse,

which suggests that anti-depressant medication is an

effective means to address depression. In her account,

Louise details how Prozac limits her personal agency, to

the point at which she probably would not have

‘‘actually gone through with it’’ (the suicide attempt).

In contrast, the identity of the ‘‘real me’’ is constructed

as a danger; the unfettered personal agency which

characterised this identity enabled Louise to act on her

suicidal thoughts and attempt to end her own life.

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299 293

Personal failure: moral discourses of depression

While the medicalised discourse was salient for many

young people, others appeared to be less willing to

position their experiences of depression within a

discourse which constructs depression as a disease.

Young people’s expressions of alternative considerations

of depression focused on explaining the contribution of

depression to suicidal behaviours by drawing on a moral

discourse. Informed by traditional socio-cultural under-

standings of suicide as indicative of deviance, insanity

and overall questionable integrity, the moral discourse

constructs suicidal acts as a signifier of personal failure.

Within this discourse, suicidal behaviours are con-

structed as resulting from experiencing particular life

events which may (for example) diminish dignity or

reduce happiness, these being important attributes of a

sense of self in contemporary western cultures. While

distinctly different from the medicalisation discourse in

that it does not emphasise the professional voice, the

moral discourse is similar in its suggestion of a

mechanistic inevitability between depression and suici-

dal behaviours.

Negotiating relationships with the moral discourse

became, for some young people, a site of struggle and a

point at which identity became contestable. For these

young people, this struggle was best articulated by

describing a sense of having two separate identities:

depressed and non-depressed. For many young people,

drawing upon an analogy of having ‘‘two faces’’

appeared to be an accessible way of expressing the

complexity of identifying with the moral discourse. For

example, in the following extract, Jill describes the

difference between her identity when she is ‘‘feeling

really low’’, and when she is ‘‘feeling good and happy’’:

I just think that when I’m feeling really low, really

down there’s a huge transition between that person

and when I’m feeling good. And when I am feeling

good and happy and things are going quite well, the

depressed person who is capable of doing something

like that (attempting suicide) just seems really far

away like a nightmare.

For Jill, identifying as a ‘‘depressed person’’ is

constituted by a sense of behaving in an out of control

manner, as indicated by her attempt to end her own life.

Additionally, by constructing an alternative identity, Jill

minimises her agency and responsibility for her suicidal

behaviours. She suggests that it was the flawed

‘‘depressed person’’ who decided to attempt suicide,

rather than her ‘‘authentic self’’ (Stoppard, 2000), that

is, the person who she is when she is feeling good and

happy.

Angela attempted to end her own life following the

breakdown of her de facto relationship, which resulted

in her becoming the sole care giver of three pre-school

aged children. However, Angela suggests that it was not

the stresses of sole parenting which resulted in her

suicidal behaviour. Similar to Jill, Angela also positions

herself as a flawed individual, emphasising the lack of

personal agency and control, which she associated with

her depressed ‘‘face’’:

I was always the sort of person that would act really

happy. This year is the only time that anybody said

to me ‘‘I’ve never seen you like this’’ ‘cos I’m always

like really happy go lucky. It’s sort of like I have two

faces—that’s how I feel my personality is. It’s like

this is the face I present to the world and I’ve had

that as long as I can remember. Even in my worst

depression I can still have the two faces. But this year

it just got to the point where it was just like I couldn’t

have the two faces anymore. It was just like I was just

so exposed and everyone saw me at my worst.

Drawing upon the moral discourse Angela suggests

her struggle between the juxtaposition of her ‘‘two

faces’’ has been a life-long effort, and it was when she

was unable to continue struggling ‘‘this year it just got to

the point where it was just like I couldn’t have the two

faces anymore’’ that the suicidal behaviour occurred.

With her declaration ‘‘I was just so exposed and

everyone saw me at my worst’’ Angela articulates her

sense of personal failure associated with being unable to

successfully maintain the facade of her non-depressed

identity to a public audience. Previous research has

suggested that a lost sense of identity is a characteristic

of depression (Stoppard, 2000). For Angela, it appears

that publicly losing the struggle between her depressed

and non-depressed identity was sufficient to result in her

attempting to end her own life.

Brett was originally given Prozac to alleviate his

persistent negative emotional state following the dis-

covery of his fianc!ees infidelity. In contrast to Louise’s

earlier construction of anti-depressant medication with-

in a medicalised discourse, within the moral discourse

descriptions of interactions with anti-depressant medi-

cations, such as Prozac, constructed such medications as

the antithesis of a safety net. For example, in the

following account, Brett positions Prozac as the primary

contributing factor in his suicidal behaviours.

I hung on for two years but I just gave up in the end

and took a knife to myself. They actually put me on

Prozac. Normally I had quite a good survival drive

because I’ve attempted it in the past but my body

would just lock up and wouldn’t actually even let me

make a cut at all. But on the Prozac I just didn’t give

a shit anymore and I just did it.

Questioning the assertions of the medicalised

depression discourse which privileges anti-depressant

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299294

medication as the appropriate treatment for depression,

in this account Brett draws upon a mechanistic discourse

to explain the interconnections between anti-depressant

medication and suicidal behaviours. He constructs an

identity of a ‘‘non-Prozac self’’: a man who is controlled

by naturally occurring biological drives and urges. Brett

suggests these drives and urges are positive protection

mechanisms against suicidal behaviours. For example,

he has a ‘‘good survival drive’’ which had prevented him

acting on his suicidal thoughts for 2 years: ‘‘my body

would just lock up and wouldn’t actually even let me

make a cut at all’’. However, drawing upon a moral

discourse, Brett constructs an identity of a flawed self-

on-Prozac. He suggests that by colluding with the

medicalised discourse and accepting treatment by

Prozac, this interrupted his natural process and sig-

nificantly reduced a previously ‘‘good survival drive’’ to

the extent that he ‘‘just didn’t give a shit anymore’’, and

attempted to cut his throat.

Fear of stigma: negotiating relationships with dominant

discourses of depression

Willig (2000) suggests that examining resistance to

dominant discourses enables the examination of alter-

native subject positions as well as subversive practices.

The dominance of the orthodoxy of the medicalised and

moral discourses of mental health issues is evident when

young people’s talk is examined to explore resistance to

these discourses. For many participants, the process of

resistance to these dominant discourses was limited to

articulating their fears related to mental ill-health

concerns. Discussions of stigma associated with mental

ill-health formed the primary site of young people’s

negotiations between the medicalised and moral dis-

courses. A former ‘‘high achiever’’, Jane was diagnosed

as suffering from depression after she became increas-

ingly withdrawn and absent from school. In her

discussion of her fears of stigma, Jane negotiates

between positioning herself within the moral or medi-

calised discourses;

Like depression, it’s not like ok, you’ve got a rash or

something, you can physically see this is what’s

wrong with you. The symptoms of depression—if

someone straight asks you are you feeling depressed,

well, yeah, it’s hard to answer. I guess I was for ages

trying to find any other reason for feeling that way

you know—give me some blood tests or something

must be wrong with me, you know—my iron is low

or you know or something is wrong. Something other

than depression. I guess for me it’s got a little bit of a

stigma—it would be better to have something

physically wrong with you. If you have a physical

illness, it’s nothing to do with what you’ve done. It’s

something external, you know, you broke your leg or

you’ve got some disease, and it’s not because of

anything that you’ve done. I s’pose depression is

something to do with a sort of state of mind. It’s who

you are and if you can’t cope then you’re sort of you

know, oh you’re sort of a bit of a failure.

In her discussion, Jane suggests that there is a

hierarchy of stigma associated with depression, and

suicidal behaviours. In Jane’s account, she suggests that

the greatest stigma is associated with the construction of

subjectivity within the moral discourse. She suggests it is

‘‘better to have something physically wrong with you’’

than be judged to be intrinsically flawed and a failure. In

this account, the aetiology of depression is ‘‘something

to do with a sort of state of mind’’, and Jane suggests

that not being able to appropriately ‘‘cope’’ with life’s

experiences means that ‘‘you’re sort of a bit of a failure’’.

However, stigma is also a problematic issue within the

medicalised discourse. Some health concerns and ill-

nesses, suggests Jane, are more socially acceptable than

others. For example, physical illness is the least

stigmatised as it is not associated with personal

accountability: ‘‘it’s nothing to do with what you’ve

done’’. Additionally, internal illnesses which are con-

gruent with expected health concerns of young women

are not stigmatised: ‘‘give me some blood tests or

something must be wrong with me, you know—my iron

is low’’.

Young people’s discussions of stigma also indicate

how closely aligned the medicalised and moral discourse

of depression are. Dave was also diagnosed as suffering

from depression as a result of his persistent negative

emotional state and increasing withdrawal from his

friends, family and school contacts. In the following

account, Dave articulates his struggle to be identified as

‘‘depressed’’ in a way which is not associated with

negative social judgements:

I guess when you get really depressed you’re

thinking, oh nobody could possible feel like this,

nobody could possibly be more depressed than I am.

You don’t realise that other people are going through

it as well. It almost seems hard to comprehend, you

know to see so many people out there doing the same

thing. And I don’t think there is much recognition of

it from other people. That’s why I find it hard to talk

to people and hard to sort of come out of the closet

sort of thing. Well, it’s not really something that you

could sort of announce, I mean when you have

cancer or something, you say, oh no cancer. But if

you say, hey I’ve got depression, people treat you like

you are mental, you are like crazy or something,

you’re a freak or fucked up something like that. It’s

like you’re mental or something.

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299 295

At the beginning of his narrative, Dave draws on the

moral discourse of depression, and suggests to be

depressed is an indication of his personalised failure:

‘‘nobody could possibly be more depressed than I am’’.

However, he acknowledges that depression is an

experience that is shared by other members of the

community as well: even if it is not publicly acknowl-

edged ‘‘other people are going through it as well’’. By

suggesting that depression is something which anyone

could potentially experience, depression is like a disease

which may strike at random. However, attempting to

destigmatise depression by positioning it within the

medicalised discourse is complex, as depression is not

the same as other diseases. Similar to Jane, Dave

articulates a hierarchy of diseases: cancer is more

acceptable than depression. In contrast, depression is a

disease associated with secrecy and silence: it is ‘‘hard to

sort of come out of the closet’’ to announce to the

community. In his narration of the negative social

judgement associated with depression, Dave appears to

indicate that the orthodoxy of the moral discourse of

depression is more salient and powerful than the

medicalised discourse.

The stigma associated with the moral discourse of

depression appears to be based on a binary construction

of normal/abnormal as indicated by mental health

status. The moral discourse suggests that those who

experience depression and/or suicidal behaviours are

‘‘other’’—that is, distinctly different to the rest of the

community. Young people suggest that the salience of

this normal/abnormal binary may be a powerful barrier

to reducing the stigma associated with mental health

issues. In the following extract, Jill discusses the impact

of negative judgements on her feelings about herself as a

‘‘normal’’ young person:

There is a stigma involved, or a stigma attached to

any kind of suicide attempt or depression. Normal

people or people who haven’t been there, think of

you as being crazy or mental and definitely don’t

understand that normal people can become depressed

or have this happen. But you’re not insane, you’re

not mental and I just think that is the stigma that’s

attached to it.

In the above account, the moral discourse suggests

that depression and suicidal behaviours are a conse-

quence of being ‘‘crazy or mental’’. However, Jill

attempts to refute this by constructing depression as a

disease, within a medicalised discourse. Similar to Dave,

Jill constructs depression as a disease to which anyone

may be exposed at random: ‘‘normal people can become

depressed or have this happen’’. By drawing on the

medicalised discourse, Jill attempts to refute judgement

about her mental health status ‘‘you’re not insane,

you’re not mental’’, but appears to be fatalistic about

the probable lack of success of her endeavours: ‘‘I just

think that is the stigma that’s attached to it’’.

Concerns relating to stigma and mental ill-health were

not limited to the experiences of young people. Mary’s

extended family included a number of people who had

received diagnoses of various mental illnesses. This, she

suggested, informed both her own and her parent’s

perspectives about the stigma of mental illness. In the

following account, Mary reflects on her parents’

concerns for her future, should her history of depression

become public knowledge:

My parents are worried that people will find out and

it will come back to haunt me in future years. I’m

hoping like hell that in future years being mentally ill

is just like having something else wrong with you and

you know, it’s fine and people get that. But I guess

they’re just worried there’s still going to be sort of

stigma attached to it, and that through no fault of my

own I will be persecuted for it I guess.

Similar to Jane and Dave, in this account Mary draws

upon a hierarchy of socially acceptable diseases.

Depression is constructed as a disease that is distinctly

different from other health concerns: it is not ‘‘just like

having something else wrong with you’’. In this account

Mary indicates that depression is constituted by

discourses of fear, stigma, and the potential for

persecution. While Mary suggests that ‘‘in future years’’

this may not be the case, currently the most effective

answer to addressing negative social judgements asso-

ciated with depression is to keep it as a private

experience. However, in articulating her parents fears,

Mary suggests that being discreet about her depression

is something which must be undertaken with great care

to reduce any potential that ‘‘through no fault of my

own I will be persecuted for it’’.

As a means of challenging the potential stigma

associated with being publicly identified as ‘‘depressed’’

a number of young people accessed a discourse of

normality to minimise their lack of difference to their

peers and family members. By drawing upon this

discourse, young people attempted to challenge the

constructions of depression as indicative of either

disease or personal failure, and to minimise the potential

of negative social judgements being directed towards

them. The normality discourse was constituted by an

emphasis on the (pre-suicidal behaviours, and pre-

depression) status quo. Emma attempted to end her

own life after what she described as ‘‘an ordinary

argument’’ with her parents. In the following extract,

Emma positions herself within the normality discourse

to minimise the potential of any negative judgements

about her mental health from her peers:

My friends were all really upset about it and they

came to see me. I think a lot of them like they said

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299296

they weren’t really upset until they saw me like the

next day. But I was quite happy and glad to be alive.

They thought I might be really depressed and they

were quite reassured when they saw me at the

hospital so they felt a lot better. They’ve been real

good and don’t treat me any differently or anything.

I was worried what was going to be going on at

school. I didn’t want many people to find out. But of

course half the school knew and there were sarcastic

comments every day and things and rumours about

why I did it and that.

Similar to Mary, Emma articulates a fear of the ways

in which the social stigma associated with depression is

likely to impact on her life ‘‘sarcastic comments every

day and things and rumours’’. However, by emphasising

her ‘‘normality’’ and by positioning herself as ‘‘happy

and glad to be alive’’ Emma effectively minimised her

friend’s fears that she ‘‘might really be depressed’’, that

is, she might be obviously different from them and

someone to be avoided. In her account, Emma indicates

that this strategy is successful as the potential for

negative social judgements appears to be reduced: her

friends have ‘‘been real good and don’t treat me any

differently or anything’’.

Brett also emphasised the importance of normality in

his reflections on the role of depression in his suicidal

behaviour. In the following account, Brett describes how

his younger brother was an important co-contributor in

Brett’s attempts to position himself within a normality

discourse:

I was really lucky to have my little brother because

he’s the only one in the family who treats me um just

normal you know. He doesn’t bother walking round

on egg shells at all. I mean if he doesn’t like

something he’ll just tell ya. You know, if he doesn’t

like your shirt he’ll say, that’s a fucking ugly shirt you

know. He helped me through it heaps because you

need people like that. You need people that will treat

you normal. Otherwise you just sort of get wrapped

up in your own little world and you get lost, you

know.

In this account, Brett suggests that being perceived as

‘‘normal’’ is important as a means of maintaining

positive mental health after a suicide attempt. Being

treated as normal, that is, the antithesis of suicidal or

depressed, is constructed as an effective barrier to future

difficulties: ‘‘otherwise you just sort of get wrapped up in

your own little world and you get lost’’. However, being

treated as normal is not unproblematic. Due to the

impact of suicidal behaviours on family members, Brett

acknowledges that to treat him as ‘‘normal’’ is not easy.

His younger brother is ‘‘the only one in the family who

treats me um just normal you know’’, while other family

members are prone to ‘‘walking around on egg shells’’.

Conclusions

The approach detailed in this article of exploring

young people’s discussions of the contributions of

mental health issues to their suicidal behaviours is

unique. The published literature relating to suicidal

behaviours suggests mental health issues, particularly

depression, are predominant in young people who

undertake suicidal behaviours. The dominance of this

as an accepted view in the suicide literature is reflected in

the findings of researchers such as Brent, Perper, Moritz,

Baugher, and Allman (1993) who contend that some

level of clinical mental illness is present in all young

people who attempt to end their own lives, even if

research findings do not ‘‘appropriately’’ illuminate this.

When discussing the contributions of depression to their

suicidal behaviours, young people drew on a medicalised

discourse which constructed depression as a disease.

Within this discourse young people’s agency (or their

ability to behave and think a certain way) was restricted,

as the voices of medical professionals were prioritised

and depression was constructed as a disease which was

difficult to resist. An alternative to the medicalised

discourse was provided by the moral discourse, which

positioned young people who experienced depression

and suicidal behaviours as failures. The orthodox power

and domination of these discourses was evident in young

people’s inability to resist being positioned, or position-

ing themselves, within these discourses. In the young

people’s talk discussions of alternative positions, or

indications of resistance to the dominance of these

discourses appeared to be silenced.

The findings detailed in this article indicate a close

alignment between the medicalised and moral discourse,

suggesting that they may operate as a binary construc-

tion. These discourses suggest that young people who are

depressed and try to end their own lives are likely to be

either suffering from a disease (the medicalised discourse)

or are in some way deficient in their character (the moral

discourse). Both discourses are predicated on a shared

understanding of a mechanistic construction of the

connections between mental health issues and subsequen-

tial suicidal behaviours. Both suggest a sense of inevit-

ability about the interconnections between depression

and suicidal behaviours, with implications for subjective

agency. The medicalised discourse prioritises the expert

opinions of health professionals, and suggests that

appropriate intervention and treatment for depression is

only that which is provided within the medical paradigm.

In contrast, the moral discourse constructs young people

who are depressed and who attempt to end their own

lives as failures, and suggests that young people are

personally responsible for their own success or failure in

addressing their mental health concerns.

Both the moral and medical discourses construct

young people who have attempted to end their own lives

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299 297

as deviant, and distinctly different from the norm. The

clearest indication of the connectedness between the

dominant discourses was evident in young people’s

discussions of their concerns relating to negative stigma

associated with experiencing mental ill-health. As a

challenge to the power of such negative stigmatisation,

young people drew upon a ‘‘normality’’ discourse as an

alternative position to either the moral or medical

discourses. However, young peoples’ talk indicated that

attempting to position themselves within the normality

discourse was complex. That young people may wish to

be treated as ‘‘normally’’ as possible in the period after a

suicide attempt is not surprising, however, for many

family members and friends it was very difficult to

regard a suicide attempt as within the realms of normal

behaviour. Not unsurprisingly, pervasive social under-

standing of suicidal behaviours as deviant, and the

antithesis of ‘‘normal’’ behaviour, provide a strong

challenge to young people’s attempts to identify

themselves as normal in the period following a suicidal

crisis. Contemporary moral discourses of deviance/

suicide are partially informed and constituted by

historical Christian understandings of suicide as a sin,

a contagious social disorder, and generally as a

fundamental affront to the community (MacDonald,

1989). Understandings of sin and deviance also resonate

within contemporary discourses constituting young

people as an ‘‘at-risk’’ population. Public health under-

standings of individual and population-based risk

factors suggest that, in general, young people are deviant

as a result of their risk-taking lifestyle, including their

propensity for suicidal behaviours. As a group, youth

are increasingly likely to be constituted as deviant types

who are identified as needing to be appropriately

controlled for the benefit of the health of the whole

population (Kelly, 2000).

The analyses presented in this article indicate that

both the medical and moral discourses of depression are

able to provide explanations for young people’s suicidal

behaviours which make ‘‘common sense’’, and which are

powerful and easily accessible to the community. Both

discourses suggest that young people who attempt to

end their own lives are always deviant, either in their

moral fibre or in their mental health status. The power

of the orthodoxy of youth deviance also has implications

for young people’s help seeking at the time of a suicide

attempt. These findings suggest that help seeking

following suicidal behaviours is a complex and proble-

matic process. Young people expressed fears of feeling a

failure, and of negative social judgements and stigma if

they ‘‘confessed’’ about their self-harming behaviours.

This results in a conundrum for young people who have

experienced a suicidal crisis: how is it possible to seek

help and care following a suicidal crisis, without

exposing oneself to the stigma associated with mental

illness?

Public health campaigns which seek to destigmatise

mental illness may offer a partial solution to this

dilemma. However, such campaigns are not unproble-

matic as they tend to reinforce and promote the medical

discourse about depression to communities. Additionally,

current public mass media destigmatisation campaigns in

New Zealand focus on the needs of adult populations,

and acknowledge the impact of negative stigma experi-

enced by adults on the likelihood of help seeking for

mental health concerns. However, findings from this

research indicate that such campaigns fail to address the

concerns of young people. Destigmatisation campaigns

are likely to be an important component of mental health

promotion programmes for young people, as they are an

opportunity to demystify mental health and may also

encourage help seeking behaviours by young people.

Analyses presented here indicate that destigmatisation

campaigns should be informed by a critical awareness of

the importance of the ‘‘normality’’ discourse for young

people who are experiencing personal distress, or who

may be experiencing mental ill-health. Additionally, from

a critical public health perspective, destigmatisation

campaigns need to challenge the taken-for-granted

assumptions connecting experiencing mental ill-health

and the potential for suicidal behaviours.

It is important to note that the current research

focuses on the experiences of young people in the period

immediately following a suicidal crisis. Consequently,

the medical and moral discourses examined here may be

context dependant to this time, and may also reflect a

temporary acceptance of a face-saving medical or

socially acceptable explanation for suicidal behaviours.

The emergence of a normality discourse appears to

suggest that the most powerful challenge to the

mechanistic construction of the connections between

mental heath disease, flawed moral fibre and suicidal

behaviour is the passage of time. In contrast to the

construction of depression as something solid or

tangible (a noun) within the medical discourse, young

people suggest that repositioning themselves within the

normality discourse is predicated on understanding

‘‘being/doing normal’’ as a process or evolving action

which occurs over time. It is likely that in the weeks

following the suicidal experience the medical metaphor

of ‘‘getting sick and becoming well again’’, and the

social transition from shame and humiliation back to

social acceptance by friends and family may appro-

priately acknowledge the young people’s transition from

deviance and otherness to normality.

Finally, there is a popular social belief which is also

reflected in the academic literature that a non-fatal

suicide attempt is a misguided form of social commu-

nication: a deliberate ‘‘cry for help’’, rather than an

intentional desire to end one’s life (American Academy

of Pediatrics, Committee on Adolescence, 2000; Den-

ning, Conwell, King, and Cox, 2000). In the time after a

S. Bennett et al. / Social Science & Medicine 57 (2003) 289–299298

suicidal crisis it is not unusual for families and friends to

strengthen social bonds with a young person, and as

such, a suicide attempt may be care eliciting. These

findings suggest that for some young people, such

behaviours may also be an expression of feeling

‘‘deviant’’, and may signal a desire to be considered

normal. Thus, it is important to recognise that unquestio-

ningly constructing a young person either as diseased or

morally flawed as a result of their suicidal behaviours

may seriously interrupt a young person’s access to care

and support at a time when they may need it the most.

Acknowledgements

This study was funded by the Health Research

Council of New Zealand and by the Alcohol Advisory

Council of New Zealand. We would like to thank the

young people who participated in this study for their

time, trust and honesty. We would also like to thank

participating hospital staff for their help with recruiting

participants.

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