By-person PCA identified four outcome priority profiles that explained 48.7% of the common variance in youth Q-sorts. Inter-component correlations ranged from 0.05 to 0.33, without reaching statistical significance at p < 0.01, suggesting that distinct preference profiles had been extracted. Two Q-sorts did not load significantly on any principal component; and one was confounded (i.e., had significant loadings on two components). These Q-sorts were not considered for further analysis . The rotated component matrix and loadings are shown in Table 2. Hereafter, we describe each of the four outcome priority profiles, as well as any consensus statements that received similar rankings across profiles. We refer to the ideal–typical Q-sorts (see Table 3) by providing statement numbers and ranks in parentheses (e.g., #3, + 3), and draw on the post-sort interviews for interpretation. Figure 2 provides an illustration of the outcomes considered most and least important by each profile. An overview of socio-demographic characteristics and treatment history by profile is provided in the Supplement (Table S1).
Common outcome themes across youth profiles
There was consensus among all four outcome priority profiles on the importance of reducing core depressive symptoms such as low mood and the loss of pleasure and enjoyment. Feeling happier and enjoying things more (#3) was ranked as a most important outcome (rank + 4) by three out of four profiles; and feeling less down and depressed (#2) was considered very or somewhat important (ranks + 2 to + 4) by all. In addition, all four profiles assigned a high level of importance to feeling more optimistic and positive about life and the future (#29, + 2 to + 4). Most consistently ranked as unimportant were improved relationships with peers in school (#23, − 2 to − 4), with many youth explaining that they did not struggle with peer relationships or bullying.
Profile A: relieving distress and experiencing a happier emotional state
Profile A represents six youth and explains 13% of the common variance. A primary desire for this profile was to overcome the distressing emotional states typically associated with depression. Young people prioritised emotional changes such as feeling less down and depressed, feeling happier and enjoying things more (#2 and #3, + 4), and feeling more loved (#4, + 3). One young person described: “I’d been feeling it for so long it was like something that I just wanted to get rid of. And especially because like ‘feeling less down and depressed,’ for a depressed person that seems like … heaven” (Becca).
Other priority outcomes also related to reaching a happier emotional state and included learning strategies to cope with emotions (#7, + 3), reducing potentially harmful behaviour (#5, + 3), having greater peace of mind (#28, + 2) and feeling more optimistic about life and the future (#29, + 2). Compared with other outcome profiles, these youth gave higher importance to becoming more sociable (#14, + 2) and getting on better with friends (#22, + 1), as they tended to describe their depression as a barrier to connecting with others. In turn, youth deprioritized outcomes related to parental support and parental well-being (#32–35, − 3 to − 4), and explained that they preferred to manage their difficulties independently or felt that their parents had a limited ability to understand and support them.
Youth in this profile had a mean age of 18.2 years (SD = 1.6); half were female. With one exception, these youth were not currently receiving treatment, but half reported that they had engaged in multiple treatment cycles. One young person had been admitted to emergency care in relation with their depression, but none had been in inpatient care. Youth reported lived experience with four additional mental health difficulties, on average, including anxiety (n = 6), sleep problems (n = 4), self-harm (n = 4), and disordered eating (n = 4). Difficulties mentioned less frequently included a neurodevelopmental disorder, problems with anger or aggression, obsessions or compulsions, substance use, and psychosis. All adolescents reported experience of individual psychotherapy, four reported experiences of taking antidepressant medication, and two each reported experience with family or group therapy.
Profile B: learning to cope with cyclical distressing emotional states
Profile B represents eight youth and explains 15% of the common variance. Although improved mood was a priority outcome (#3, + 4), these youth did not believe that treatment would provide an ultimate cure and enable them to reach a happier emotional state once and for all. Instead, they described their depression symptoms as cyclical and prioritised a range of outcomes related to gaining the coping skills and agency required to manage their symptoms independently in the long-term. These outcomes included learning to challenge negative thoughts and approach situations differently (# 9, + 4), learning strategies to cope with emotions (#7, + 3), having a better understanding of feelings and thoughts (#8, + 3), and feeling more able to talk about feelings and thoughts (#20, + 3). By acquiring these skills, youth hoped that they would be able to prevent or manage future depressive episodes:
Like when the first wave of sadness hits, normally you don’t have the strategies, you will just […] be snowballing, but […] it’s important to find ways to kind of break that momentum and stop that snowball before it just gets worse. (Jacob)
Youth in this profile were reluctant to become reliant on professional help and valued outcomes related to being independent and able to take responsibility for their own lives (#17, + 2):
When I first went to CAMHS [child and adolescent mental health services], it was a case of I just wanted to not feel this way anymore. But when I kept going back to CAMHS, then I thought, this isn’t sustainable, I need to be able to function without CAMHS so the more times I cycled through getting help, the more important sort of resilience or being able to help myself became. (Hannah)
The outcomes ranked as least important related to aspects of life that youth in this profile felt they did not struggle with, such as managing anger (#1, − 4), risky or harmful behaviour (#5, − 4), family and peer relationships (#22 and 23, − 3), or a lack of assertiveness (#16, − 3).
Youth in this profile had a mean age of 19.3 years (SD = 2.2); three out of seven were female. Half reported being in treatment at the time of the research; five out of eight reported having participated in several cycles of treatment. None of the youth reported a history of accessing emergency or inpatient care in relation with their depression. On average, youth described three additional mental health difficulties, with the most common ones being anxiety (n = 5), eating or sleep problems (n = 4), and self-harm (n = 3). Less frequently mentioned co-occurring problems included neurodevelopmental disorders, obsessions or compulsions, substance use and psychosis. None of the youth reported a history of trauma, or a struggle with anger or aggression. Youth reported experience of individual psychotherapy (n = 7), family therapy (n = 4), antidepressant medication (n = 3), and group therapy (n = 2).
Profile C: understanding and processing distressing emotional states
Profile C represents eight youth and explains 14% of the common variance. This profile focussed on finding safe outlets for emotions, making sense of past and present experiences, and gaining a more positive outlook into the future. A considerable share of young people representing this viewpoint had sought mental health support not just for depression, but also in relation to overlapping needs, including learning difficulties (n = 4), ASD (n = 3), ADHD (n = 2) or trauma (n = 2). These youth tended to feel that growing up with these difficulties had set their experiences apart from those of peers or family members, and they often struggled to make sense of these experiences themselves:
With the Asperger’s, I don’t really understand emotions in general […] I can never tell if I’m sort of truly feeling something or if I’m just thinking I’m feeling that. (Jade)
Young people with ASD in particular described anxieties about the future and their prospects for accessing higher education or employment, which in turn would affect their mood. Youth frequently described self-harm as an outlet for overwhelming emotions that they could not articulate or manage otherwise. In this context, youth endorsed a mix of outcomes that revolved around calming some of the anxieties and confusion that stemmed from experiencing the world differently, and around trying to make sense of their emotional states in order to be able to move forward:
I kind of wanna get all my thoughts in order and there’s a lot of stuff that has happened in the past that I wanna deal with before I start dealing with stuff now. (Chelsea)
In line with this, the most highly ranked outcomes included finding safe outlets for their emotions and reducing self-harm (#5, + 4), being able to make sense of past and current experiences (18, + 3), feeling more optimistic about life and the future (#29, + 4), and having greater peace of mind (#28, + 3). Youth longed to feel better understood by their parents (#33, + 3), to improve their family relationships (#22, + 2), and to have a space where somebody listened and cared about them (#24, + 3). In contrast, outcomes relating to psychosocial functioning (#11, 13, 14; rank − 3) and peer relationships (#22 and 23, − 4) were assigned low importance, with several youth explaining that they did not strive to be “typical” adolescents and that they felt at ease with a select group of friends or with being by themselves.
Youth in this profile had a mean age of 18.8 years (SD = 1.8); seven were female. Half reported that they were still receiving treatment; half had engaged in several courses of treatment; three had visited emergency care in relation with their depression; and one had spent time in inpatient care. On average, youth reported five additional mental health difficulties, with anxiety being the most frequent (n = 7), followed by self-harm (n = 6), sleep problems (n = 5) and neurodevelopmental disorders (n = 4), learning difficulties (n = 4), and obsessions or compulsions (n = 3). Anger and aggression, substance use, psychosis, and trauma were less frequently mentioned. Youth reported experience of individual psychotherapy (n = 6), antidepressant medication (n = 6), family therapy (n = 4) and group therapy (n = 2).
Profile D: reduced interference of ongoing distressing emotional states with daily life
Profile D represents three youth and explains 8% of the common variance. This profile revealed an experience marked by a constant struggle with a complex set of mental health difficulties, and a desire to recover a life and identity that would not be defined by this struggle.
Youth in this small group described considerable impairment that often had been present for years. This included, for example, having to interrupt school, being unable to go out with friends, or to use public transport. As described by Georgia: “It’s affected everything, like literally everything.” To this group, feeling happier and enjoying things more (#3, + 4), and being able to engage in age-typical activities (#11, rank + 4) were the two most important outcomes. Feeling less down and depressed was also highly ranked (# 2, + 2). In addition, these youth prioritised recovering a sense of confidence and hope (#15, + 3; #29 and 31, + 2) to envisage an identity and future beyond their struggle with their mental health:
“Who I am can feel quite dependent on my mood at that moment, and if I’m feeling very low then I’m like […] nothing’s ever gonna be worth it…” (Meghan).
These youth also worried about the impact that this struggle had had on their families and were the only profile to prioritise a reduction in parental guilt as an important outcome (#35, + 3). Contrary to other profiles, these youth did not prioritise improvements in coping and self-management (#6–9, − 1 to − 4), expressing scepticism that such strategies could be deployed at will, especially when emotions became overwhelming.
The mean age of youth in this profile was 19.3 years (SD = 1.5); two were female. Two reported that they were receiving ongoing treatment; two had engaged in several episodes of treatment; and two reported that they had been admitted to both emergency care and inpatient care in relation with their depression. Youth in this profile reported the highest burden from additional mental health difficulties (in seven areas on average) out of all profiles. All three reported anxiety, self-harm, and problems with eating and sleep. Additional difficulties mentioned by one or two youth included a history of psychosis, trauma, and issues with anger. All youth reported that they had participated in individual psychotherapy, and two each had been treated with medication, family therapy, or group therapy.
Youth suggested a number of additional outcomes that they felt were missing from the Q-set. Overcoming a sense of boredom or numbness, and finding an interest in something (e.g., a hobby or project for the future) was mentioned by two young people. Other additional outcomes were mentioned by one young person each and included improved sleep, reduced feelings of loneliness, overcoming a sense of personal guilt for the impact that one’s depression may have had on friends and family, developing the ability to trust and confide in others outside of therapy, a general sense of well-being, being able to discontinue medication, and improved productivity at work.