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             \author[1]{  Aselton}

             \affil[1]{  University of Saint Joseph}

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\date{\small \em Received: 10 December 2012 Accepted: 31 December 2012 Published: 15 January 2013}

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\begin{abstract}
        


Depression has been increasingly diagnosed in the college age population with the American College Health Association reporting 16% of all college students having been diagnosed with depression.1 In another large survey of American college students, over half reported some depressive symptoms since entering college.2 Correspondingly, the percentage of all people treated with antidepressants grew over the past two decades. On college campuses in the United States, the numbers of prescriptions for antidepressants increased between the early 1990s and 2005, with estimates as high as 25-50% of the college students being seen in student health counseling centers being medicated with antidepressants. Evidence suggesting increase risk of suicidal thoughts or behavior among children and adolescents taking antidepressants led to the issuing of a public health advisory and a government mandate for ?black box? warnings being placed on these medications in 2007.7 There is now some evidence that the trend of treating adolescents and young adults with antidepressants may be decreasing. Although much has been published on the use of antidepressants and how to identify depression in this age group, there have been few qualitative studies that explore the experience of young people who have been medicated with antidepressants.5,9

\end{abstract}


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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
epression has been increasingly diagnosed in the college age population with the American College Health Association reporting 16\% of all college students having been diagnosed with depression.  {\ref 1} In another large survey of American college students, over half reported some depressive symptoms since entering college.  {\ref 2} Correspondingly, the percentage of all people treated with antidepressants grew over the past two decades. On college campuses in the United States, the numbers of prescriptions for antidepressants increased between the early 1990s and 2005, with estimates as high as 25-50\% of the college students being seen in student health counseling centers being medicated with antidepressants. Evidence suggesting increase risk of suicidal thoughts or behavior among children and adolescents taking antidepressants led to the issuing of a public health advisory and a government mandate for "black box" warnings being placed on these medications in 2007.  {\ref 7} There is now some evidence that the trend of treating adolescents and young adults with antidepressants may be decreasing. Although much has been published on the use of antidepressants and how to identify depression in this age group, there have been few qualitative studies that explore the experience of young people who have been medicated with antidepressants.  {\ref 5,} {\ref 9} II. 
\section[{Methods}]{Methods}\par
A qualitative approach with in-depth email interviews was used to explore the experience of college students who have been medicated with antidepressants. Having had time to reflect on their experiences with antidepressants, college students' perspectives are invaluable to enhancing our understanding of the effects of these medications over time in this age group. An Internet-based approach was chosen to reduce their time burden for participation and create a comfortable environment for them to express themselves. The authors' Institutional Review Board approval was obtained before the start of data collection. Collecting qualitative data online eliminates the embarrassment some may face in disclosing sensitive information in a face-to-face interview, and subjects may be more likely to share intimate details and reflect on answers more carefully.  {\ref 12} The Accessibility of the Internet allowed for students to enter information at any time of day, and allowed time for the researcher to process that information in order to guide the discussion.  {\ref 13} The research design consisted of a phenomenological approach with online interviews utilizing concepts from Seidman's guide to in depth interviewing.  {\ref 14} Seidman's work in developing the three part interview focuses on breaking the interview into the history or background of the phenomenon under study, the experience of living it, and finally a reflection on the experience to search for meaning. The following lists the open ended question used with all these students: When were you first diagnosed with depression? Tell me something about your family and where you grew up. What was your early schooling like? Do you remember feeling depressed before college?\par
How was your first experience with antidepressants? Describe your past treatment for depression, if any. 
\section[{How did you feel about being treated with antidepressants?}]{How did you feel about being treated with antidepressants?}\par
What are some of your current sources of stress? Looking back, do you feel that antidepressants helped you deal with stress? Do you feel that antidepressants helped you deal with depression?\par
Have you ever stopped taking an antidepressant, if so, why?\par
How do you deal with feeling of depression now?\par
Students were solicited through written notices posted on four campuses and an ad put in a college newspaper. Initial response to recruitment was limited and consequently an incentive of a \$25.00 gift was later added. Data collection was started online only after participants had returned the signed informed consent form electronically. Open ended questions were used to solicit responses with additional follow up questions added as the conversation progressed. Emails were exchanged between the participants and the researcher 6-8 times to complete each interview. The total number of email pages of a typed interview varied from 5-10 pages. Interviews continued with the participants until all interview prompts had been used and questions, either the interviewer or subject posed, were answered. As the email session came to a close copies of the text in the emails were pasted into a Word document file with the participant's identity being replaced with a number, and all possible identifiers hidden from view. Although absolute anonymity can never be 100\% ensured on the internet, every effort was made to protect the subject's confidentiality. Only the researchers saw these emails, and they were kept in the researcher's office when not in use. The informed consent spelled out in detail where the student could turn to for help if the interviews caused them emotional distress and specific numbers of resources for psychological help on each campus in the area was provided.\par
The sample size of 13 is consistent with the typical sample size identified for phenomenological investigations.  {\ref 15} Inclusion criteria for this study were to be an undergraduate college student between the ages of 19 and 24 in the Northeast United States who had taken antidepressants at some point in their college years. Exclusion criteria included those who had started taking antidepressants within the past 4 weeks, since they may not have been able to reflect back on their experiences as well as those who have been on them for a longer period of time, as they may be in a somewhat more unstable state. Those who were severely depressed as evidenced by their written material or experiencing suicidal ideation were also not included in the study and were to be immediately connected with their college mental health services.\par
Open coding was begun utilizing both the Atlasti qualitative software package and by hand coding hard copies of interview transcripts. This was followed by a clustering into themes and subthemes by both the first and second readers. Thematic analysis was then utilized to analyze the data in discussions with the second readers. Thematic analysis was then utilized to analyze the data in discussions with the second reader. 11 Once the categories of themes were identified, both readers would compare notes to refine the thematic schema and discuss the meaning of the written material. Trustworthiness was enhanced by member checking to verify the accuracy of statements as the data collection turned into data analysis. Since the interviews were conducted over a period of several days to two months, both the participants and the researcher has time to formulate responses and clarify thoughts of the meaning of these experiences. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
A total of 13 interviews were completed, after having 26 subjects from 2 of 4 the colleges contacted the researcher to participate in the study. Of the 13 students who did not complete the survey: two were eliminated for having never been on antidepressants, one was eliminated for having only started antidepressants within the last week and the other 10 were either lost to follow-up or never returned their screening or informed consent forms. Of those who did complete the survey, five were male and eight were female. Twelve attended the large state university in the area and one attended a private female undergraduate college. Their ages ranged from 19-22 years of age. Although the majority of the respondents identified as white or Caucasian under ethnic background on the screening form, one student identified as African American, one as half Russian and half Polish and one an Asian American. All attended four year colleges in New England and had been medicated with antidepressants for a period as short as one and a half weeks, in one case, to several years in others with the majority having been on them for at least several months. The major themes extrapolated from the data fell under the headings of:\par
Childhood and adolescent experiences: perception of younger self, personal and family history of depression and anxiety.\par
College experience: roommate issues, pressure from family, academic problems, financial and career concerns, someone to talk to. 
\section[{Feelings about being medicated:}]{Feelings about being medicated:}\par
medications not helping with depression, family pressure to go on medication, feeling numb, masked causes of depression, embarrassment, problems weaning off antidepressants.\par
The following text illustrates the major themes identified in this study using the participant's words. 
\section[{a) Childhood and adolescent experience Perception of younger self}]{a) Childhood and adolescent experience Perception of younger self}\par
several participants described being very shy while they were younger, having difficulties in school socially and have a history of depression or anxiety.\par
"I was very shy as a kid and dreaded school more often than not".\par
"I would get into trouble a lot get called out in the middle of class by a Teacher, which is one of the reasons why I believe I continue to be very self conscious".\par
"I can recall feeling anxious for a long time, particularly in social settings, possibly as early as 5 th grade. I began to feel depressed in high school. In retrospect, I can separate the "depressed feelings" I had then from my current bout of depression. In high school, I was filled with angst and a general distaste for what was considered the norm. When I look back on how I considered myself "depressed" in high school, it Seems juvenile compared to how I feel now".\par
Another student who started on Paxil in sixth grade remembered feeling very anxious as a child: "I was very anxious as a kid. It started out as separation anxiety around first grade"\par
Several students mentioned either a family history of depression, anxiety or substance abuse. "The people I call family are my mother and my sister. Everyone outside that circle that is related me is severely dysfunctional. My grandfather on my mom's side was very abusive to my mother and her sisters. He was an alcoholic." Another student was aware of the struggles with his family's mental history and indicated that the family had discussed these problems and were open to addressing them if they came up in later generations.\par
"My paternal grandfather died by suicide?My maternal grandfather had some problems while in his 20s with substance abuse and depression. He was also a problem drinker but has now been sober for close to 10 years. My mother has suffered with anxiety since she was a teen as well as my uncle on her side of the family". 
\section[{b) College experience Roommate issues:}]{b) College experience Roommate issues:}\par
Several students mentioned problems with roommates as being a major stress in college.\par
"Another thing causing me stress is my living situation. The whole roommate thing, just at (previous college) and here, has not worked out for me. I always have the drunken girl, the girl whose boyfriend sleeps over every night, or the girl who doesn't leave her room.\par
Although the roommate I have now is better than the THREE I had before, I am still finding myself annoyed at her for wanting to stay up late and watch movies while I sleep, or sleeping until noon while I am up at 7:30 and out starting my day at 8:00 AM".\par
Pressure from family: Some students continue to feel significant pressure from their parents to achieve. One student worried about the cost of her college education and the burden it was placing on her family since her father was out of work. She also felt she was being harassed by her father, perhaps because of financial concerns.\par
"It's just continued pressure from home that bothers me, but only when I'm visiting home and in their presence?Continued sources of stress include school (performance pressure from my parents), love life and fear of being verbally harassed by my father?My father has been unemployed for about a year so I sometimes worry if I'm being a financial burden on my parents".\par
There are also major sources of stress stemming from the family of origin.\par
"I am the first of my family to go to college. I am also the oldest so there is pressure to succeed and be an example for my younger sister. Pressure to secure a job -my livelihood for the future?I also worry about my Mom a lot".\par
"Continuing friction with my family creates an undercurrent of stress in my life, as there is little beyond interpersonal conflicts and very little in terms of emotional support or validation".\par
Academic Problems: "It might be of relevance to note that I was put on academic probation at the end of my first semester on campus since I ended up with less than a 1.00 GPA. It may have been due to a combination of continued pressure from home as well as not being used to such a different environment with so many people". 
\section[{Financial and Career Concerns:}]{Financial and Career Concerns:}\par
Academics and financial issues were a major source of stress for these students. They worried a great deal about their future career plans, and the fact that college was costing their parents a great deal of money. Several expressed the desire to do well academically in appreciation of their parent's investment in their education.\par
"I want to do the best I can, I don't want to settle for anything less than As. I often put things off, or become so stressed and overwhelmed that I freeze and don't do my work".\par
"My major and my future is a major source of stress for me at the moment. I am still undeclared and waiting to see if I get accepted into the major I want.\par
Not knowing what will happen stresses me out a lot since if I don't get accepted I will be very behind. I am always in debt. The future, employment after I graduate, where I will live, how I will pay rent, how I will fund my graduate education. I am constantly thinking about this and how it all seems insurmountable". 
\section[{Someone to talk to:}]{Someone to talk to:}\par
A prominent theme in these interviews was the importance of friends to college students.\par
"I have a lot of good friends. There are only a few I will talk to like this though. I'm not normally one to express emotions, but when I need to there are a few good long term friends that I can comfortably say anything to".\par
Another major source of support for several students was their mother. Four students actually cited talking to their mother as a major source of support. 
\section[{c) Feeling about being medicated}]{c) Feeling about being medicated}\par
Medications not helping with Depression: Most of the students felt that being on medication did not help them cope with depression any better than not being on medication. Some found the side effects troublesome, while others stated that they were Stressed out just by being on medication. Family and friends; none of them seemed capable of providing the emotional support that I needed. I had talked to a counselor under duress from my mom after a particularly bad blowout had her "concerned" for me, but mostly angry at how I treat her. That summer I had to go back to the psychologist who had seen me earlier who recommended that I go to a psychiatrist who then gave me a prescription".\par
This same student later went on to state that she only stayed on the medication for a week and a half because she felt they weren't doing anything for her but ( D D D D ) B making her drowsy. She sums her feelings about her experience with antidepressants below: "I felt dehumanized. It felt as though the greatest concern was protecting the mentally sound people around me and placating me was the only way to do it. It was a difficult process to be scrutinized in front of family members and it was challenging to feel that everyone was straining to help with my problems".\par
Feeling numb: Several students reported feeling numb on antidepressants.\par
"I absolutely hated taking antidepressants. I think they mute people. It makes you a blank human being who is unable to fully express emotions. I would rather have some crazy ups and downs than be static. This is why I stopped taking antidepressants. I've actually been fine and it's been about four months".\par
"I no longer wish to be on the SSRI and wish to stop taking it. I hate the fac that my mind is being chemically conditioned daily. I have a hard time remembering what kind of person I was prior to taking the SSRI. I feel as if I am a numbed version of myself. I long to be happy and to remember what it is like to feel "naturally" happy and content. I feel that for asa long as I am on the SSRI, any feeling or reaction that I have to my environment is not genuine. I detest the fact that what is happening in my brain is due to chemical therapy". 
\section[{Masked causes of depression:}]{Masked causes of depression:}\par
Many students stated that they really did not like taking the medication and some felt that it may have masked symptoms, rather than helping them to deal with the root causes of depression.\par
"I think the Zoloft made me have a lack of assertiveness, a little more easy going, but not being all there -if there was some debate going on that I would love to have jumped into and be involved in, I might have sat back and watched, feeling like what I had to say was not important enough to be said". This sense of detachment and feeling like she wasn't herself led one female student to discontinue her antidepressants.\par
"Ever since I've been put on the Zoloft, I haven't been "me". I question all my thoughts, and find myself annoyed or frustrated way more easily than I used to. This is why a few weeks ago, under the supervision of my doctor, I have started to wean down from 50mg a night to 25mg a night".\par
Students expressed concern that they were covering up their problems by being on medication and not getting to the root of their problems.\par
"Some (antidepressants) helped with stress and depression more than others, but there is no panacea or cure-all and I wish there was something that was. They don't cure the source of the stress and depression after all".\par
Embarrassment: Several students felt embarrassed by taking medication. One female student felt that the medication had a positive effect, but was embarrassed about taking them.too much caffeine, PMS, physical ailments?it's all about keeping myself positive and putting the triggers for anxiety in the back of my mind so it won't alter my everyday life". 
\section[{Writing or journaling:}]{Writing or journaling:}\par
Female students mentioned writing or journaling as a way to unwind and feel better.\par
"I talk to my boyfriend, write in my journal. I try to change the anxiety to excitement, for example if I have a project to do that I'm really stressed about, it helps if I have some really nice paper and a pen to use to help me create the project, because I enjoy the process a little more, rather than worrying about producing the end result".\par
Another student cited making lists as a way to help her relax.\par
"If I am stressed out about things I have to accomplish I like to make lists, it really helps me visualize what I have to get done, and really put it in perspective -usually I feel like I have so much to do, but in reality once it's down on paper, it is not so bad. I try to find and recognize places and feelings of calm and comfort. I try to take more time for myself. Mostly though, I write my thoughts and feelings that trouble me down in a journal. This has been the most effective way for me to clear my head".\par
Physical activities: Physical activity was cited frequently as a way to relieve stress. Students mentioned running, playing hockey and basketball as ways to relieve their stress.\par
Music: Many of the male students mentioned listening to music to calm them down.\par
"I either listen to relaxing music, give myself a pep talk and try to calm myself down rationally, or just wait for it to pass?I love music and movies. I play the drums, but I can't do that here unfortunately: there's no room for my drum-set in my dorm room".\par
"I found it very helpful to separate myself from whatever it is that makes me feel depressed and relax and listen to music. Listening to music has really helped calm me down and forget about my worries". 
\section[{Positive response to talk therapy:}]{Positive response to talk therapy:}\par
the majority of students who had been in therapy found it to be very helpful as illustrated in the following quotes: "Yes, therapy has been very helpful. Unfortunately nothing that I have done has had significant lasting effects. It;'s often good tojust talk about things that are on my mind or triggers my anxiety. I think it is characteristic of anxiety to have irrational fears that you need validated, but also told are unrealistic or improbable".\par
Advice to others: The process of self-actualization often led to a realization that they did not need medication and needed to deal with their problems on their own. "Know thyself. And realize that the goals that others and society impose on you aren't necessarily what you were place here to achieve."\par
"Understand your motivation for thinking the way you do, and stop to make sure That the relationships you're in are really helping you grow. Realize that things can get better".\par
"I would advise him or her to isolate the source of sadness and how it can be alleviated or resolved. Unless his or her every day is disrupted (that is not getting out of bed, inability to participate in daily responsibilities, self neglect, etc) I would not advise the use of antidepressants".\par
IV. 
\section[{Comment}]{Comment}\par
The variety of experiences offered in these online interviews provides a snapshot of the college experience for students who have been on antidepressants during a time of great change in their lives and new responsibilities. Allowing the experience to be expressed in the student's own words gave them a chance to reflect on the meaning of their experiences, and many expressed the feeling that antidepressants were not a "panacea" or cure-all. A few felt that they got them through a hard time, particularly those who also suffered from anxiety symptoms.\par
Most of the side effects participants described are well known in the literature including suicidal ideation, dry mouth, sedation and sexual dysfunction.  {\ref 16} Students in this study expressed feelings of shame or embarrassment they had to depend on a pill, and concerns that the antidepressant medication was somehow changing them into someone who they were not. The increase stimulation and agitation are well known effects of SSRi antidepressant therapy, particularly when one is just starting medication and may lead to suicidal ideations or actual action 1. . However, the description of feeling numb or not themselves is a more unique finding, and probably a result of using a qualitative approach for this topic. This was often cited as a reason for discontinuing the medication. The participants expressed a desire to experience the full range of emotions again, and not be muted. A recent study in the British Journal of Psychiatry describes an emotional side effect of antidepressants as feeling "blunted" which seems similar to feeling numb  {\ref 17.} Another study which reviewed 35 clinical trials of antidepressant drugs submitted to the U.S. Food and Drug Administration, concluded that "patients taking antidepressants fared no better than patients taking a placebo" in patients who were either mildly or moderately depressed  {\ref 16} . The drugs only seemed to benefit those who were severely depressed. The potential to cause possibly life threatening side effects weights heavily on clinicians as they struggle to treat students as major depression in itself is a risk factor for suicide.\par
These students are coping with the changing job market due to a recession and are being raised by parents who have certain expectations for their success at college and ability to obtain meaningful employment. This has lead to increased stress for both parents and students. The self actualization process many students experience during their college years is a valuable process of learning about oneself and how to be happy. Several of the students who participated in the study actually said that they found writing about their experience to be therapeutic.\par
Limitations of this study include the possibility that students who felt more strongly about their experience may have been more likely to volunteer, and the fact that the study relied on self report of diagnosis, medication history and side effects. We had a fairly select population attending four year colleges with perhaps more family support than 18-24 year old not attending college. The use of email interviews may be a limitation in that you are not able to observe the participant during the interview and read body language. However, the comfort level of talking online about these issues may balance this limitation.\par
Future research may focus on more online postmarketing qualitative approaches and could be used in studying common medications to determine how well certain classes of medication are actually working for people in their daily lives. The possibility of using the internet for qualitative studies affords many benefits to both the researcher and participant in terms of ease of use and the comfort in which the participant can express their feelings.		 		\backmatter  			  				\begin{bibitemlist}{1}

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