PLoS One. 2021;
16(6): e0252913. Wen Lin Teh, Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation,
Visualization, Writing – original draft, Writing – review & editing,1,* Ellaisha Samari, Data curation, Formal analysis, Investigation, Project administration, Software, Writing – review & editing,1
Laxman Cetty, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – review & editing,1
Roystonn Kumarasan, Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing,1 Fiona Devi,
Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing,1 Shazana Shahwan, Conceptualization, Data curation, Investigation, Methodology, Supervision, Writing – review
& editing,1 Nisha Chandwani, Conceptualization, Data curation, Investigation, Project administration, Resources, Writing – review & editing,2 and Mythily Subramaniam, Conceptualization, Funding acquisition, Resources, Supervision, Validation, Writing – review & editing1 Stephan Doering, Editor Illness perceptions form a key part of common-sense models which are used
widely to explain variations in patient behaviours in healthcare. Despite the pervasiveness of depressive disorders worldwide and in young adults, illness perceptions of depressive disorders have not yet been well understood. Moreover, while a high proportion of cases of depressive disorders reside in South-east Asia, few have explored illness perceptions that are culturally relevant to this region. To address these limitations, this study aimed to understand illness perceptions of young adults
diagnosed with depressive disorders. Face-to-face semi-structured interviews were conducted among Chinese, Malay, and Indian young adults aged 20 to 35 years old, who were seeking treatment at a psychiatric hospital. Data reached saturation after 33 interviews (10 to 12 interviews per ethnic group) and five themes emerged from the thematic analysis: 1) A reduced state of being experienced at a point of goal disengagement, 2) the accumulation of chronic stressors in a system that demands success
and discourages the pursuit of personally meaningful goals, 3) a wide range of symptoms that are uncontrollable and disabling, 4) poor decision making resulting in wasted opportunities, with some positive takeaways, and 5) accepting the chronicity of depression. Young adults typically experienced depression as a reduced state of being and it was thought of cognitively as an entity that may be a part of or separate from the self. Over and beyond these aspects of cognitive representations was the
emergence of themes depicting conflicts and dilemmas between the self and the social environment that threatened self-identity and autonomy. Addressing these conflicts in therapy would therefore be of utmost relevance for young adults recovering from depressive disorders in the local setting. The term illness evokes not only the experience of symptoms and suffering, but also the judgments, interpretations,
coping, and help-seeking behaviours that go with it [1]. The construction of illness, as explained by the theory of social constructionism, is shaped, and influenced by sociocultural forces, providing social meaning to the experience of a disease
[2]. In the context of illness and health, illness narratives serve as the most instinctive way of communicating the social construction of diseases [1,
3]. Illness narratives form a key part of explanatory models or common-sense models, which are used widely to explain variations in patient behaviours in healthcare. Examples of such models include the health belief model
[4], the theory of planned behaviour [5], and the theory of self-efficacy [6]. One popular model is the
Common-Sense Model of Self-Regulation (CSM) by Leventhal, which posits that individuals are active problem-solvers who try to understand their illness so as to cope with it [7–9]. Individuals do so by formulating their own set of cognitive
representations of illness to self-regulate and manage health threats associated with their illness [7]. The central aspect of CSM is the use of ‘lay’ beliefs to predict health-promoting or coping behaviours. According to the model, illness representations of any illness comprise of at least five dimensions: 1) Identity: symptoms that are perceived to
be part of the illness, 2) Time-line: acute or chronic in duration, 3) Consequences: the extent of the impact on individuals’ lives, 4) Causes: whether the illness is due to internal or external causes, and 5) Cure or control: the extent to which the illness is curable or incurable. The model also consists of two independent processes (cognitive and emotional) that deal with the representation of fear or danger of illness threats which trigger coping mechanisms and outcome appraisals thereafter
providing feedback to the model [7]. The CSM is one of the most widely used, due to its good psychometric properties and applicability in predicting self-care behaviours and recovery in physical illnesses [10,
11]. Increasingly, CSM is being applied to mental illness research as a way to understand and predict patient behaviours. Unlike other health belief models, CSM comprises of emotional illness representations, which are directly relevant to mental illnesses, making it a useful guide
[12]. In their review article, Lobban and colleagues detailed numerous studies that were consistent with the CSM and had described how the model is able to explain and fit the mental illness experience [12]. However, several
authors have highlighted limitations over the applicability of CSM in mental illness as opposed to physical illnesses [12–14]. While CSM is a useful guide, it has been criticized to be overly simplistic in explaining illness representations
of mental illnesses [12, 15]. Unlike physical illnesses, the cause-and-effect associations in mental illnesses are far less clear as there are greater variations in the causal beliefs and experiences of mental illnesses. Individuals often
struggle to accept mental illness [13, 16, 17]. Coming to terms with the illness is neither straightforward
nor coherent [13, 18], such that individuals may express different illness beliefs simultaneously even if those beliefs contradict each other
[14]. Moreover, unlike the case of physical illnesses where there is a clear distinction between the self and illness, the boundary between mental illness and the self is far less clear and often intersects. As a result, individuals with mental illnesses do not always see their symptoms in a negative light. Higbed and Fox’s qualitative investigation into thirteen
patients with anorexia nervosa, reported that individuals who felt the condition was a meaningful part of their identity were reluctant to do away with the illness [19]. Pedley and colleagues’ qualitative investigation into sixteen people with obsessive-compulsive disorder found that participants perceived their symptoms positively as a sort of peculiarity in their
personality, rather than viewing them negatively as symptoms of an illness [20]. Thus, unlike physical illnesses, mental illness symptoms are not always undesired and this has crucial ethical implications in the context of treating mental disorders where the patients’ definitions of recovery are often overlooked. Yet consolidating an explanatory model
for mental illness remains a challenge as patient narratives differ considerably by the type of illness. Perceptions of more common forms of mental illnesses, such as depression or anxiety, are more varied as compared to less common forms, such as schizophrenia [14], with the former conditions being more dependent on what is considered to be culturally accepted
expressions of “distress” [14]. For instance, Asian patients with depression tend to describe illness complaints as physical rather than psychological, such as reporting to feel ‘tired’ rather than ‘sad’, since the psychological labelling of symptoms is often stigmatized in non-western cultures
[21]. In another example, mental illness is more likely to be attributed to a ‘weakness of character’ in Japanese individuals as compared to Australian individuals, who are more likely to attribute it to physiological reasons [22]. These
examples depict the role of culture, its influence and interaction with personal beliefs in the social construction and experience of illness [23]. Till date, the majority of qualitative work have been conducted amongst severe but less common forms of mental illnesses, such as psychosis or schizophrenia
[12, 14], while qualitative investigations into more common forms of mental illnesses, such as depressive disorders are few and far between. Within the context of depressive disorders, the majority of existing studies have been conducted
among individuals with ongoing primary physical conditions who also report depressive symptoms, patients who meet criteria for depression based on self-report and cut-off scores, or among healthcare professionals [24–27]. Yet, only a few
have been conducted amongst individuals who are formally diagnosed with depressive disorders and who are seeking psychiatric care [28, 29]. The World Health Organization (WHO) estimates that approximately 4.4% of individuals
suffer from depression worldwide [30]. According to the same report, the majority of cases reside in South-east Asia (27% of cases), followed by the Western Pacific region (21% of cases), Eastern Mediterranean region (16% of cases), the Americas (15% of cases), European (12% of cases), and African regions (9% of cases)
[30], yet few studies have explored illness perceptions that are culturally relevant to this region. Furthermore, understanding the culture surrounding young adulthood ensures that mental health services stay relevant to their needs; needs which have grown more complex today than ever before
[31]. Young adulthood is arguably the period where an individual is most productive in life and from an economic standpoint, mental illness can pose a significant threat to productivity and disease burden. This is crucial for Singapore as human capital is considered to be an important asset
[32]. Major Depressive Disorder (MDD) is the most pervasive disorder among young adults aged 18 to 34 years in Singapore [33] and has a significant treatment gap
[34]. Thus, understanding how illness is experienced among young adults would be important for interventions at the initial stages of disease onset. To the best of our knowledge, there has been no qualitative inquiry into illness perceptions of depression that is specific to a non-western psychiatric population in Singapore and while it is typically assumed that
non-western communities have more spiritual/traditional narratives of mental illness [21, 22, 35], a highly
globalized multi-ethnic society such as Singapore may present illness narratives that are culturally distinct; it is not uncommon for Singaporeans to simultaneously utilize both allopathic and traditional forms of treatment in a multifarious medical system
[36–38]. The present study aims to explore illness representations in individuals with depressive disorders in Singapore. The two main research questions are: 1) What are the illness perceptions of young persons with
depression in Singapore? and 2) How does the role of culture influence illness perceptions in young people diagnosed with depression locally? While the nature of our inquiry is exploratory, we would expect illness perceptions to be highly associated with the self. Additionally, these dimensions are also expected to be more complex, reflecting a combination of both allopathic and culturally derived concepts of illness representation. Convenient and purposive sampling were utilized for recruitment. Recruitment was conducted in two ways: individuals were primarily referred to the research team by their clinicians during their outpatient visit or inpatient stay or were approached at the outpatient clinics by a member of the research team with information flyers that described the study. The inclusion criteria: Singapore citizens or permanent residents, aged 18
to 35 years, with a Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) diagnosis of depressive disorder, receiving outpatient treatment at the Institute of Mental Health (IMH), and were able to speak, read, and write in English. The exclusion criteria: patients with a diagnosis of substance-induced depressive disorders, depressive disorder due to a general medical condition, post-natal depression, bipolar disorder, and depression with psychotic symptoms. All consent
taking procedures (both verbal and written consent) were conducted by members of the research team and not by their referring clinicians to prevent coercion. Participants who verbally agreed to be interviewed were re-contacted within a few days but no longer than a week later via phone contact. Patients were then asked a second time over the phone if they were willing to be interviewed. This ensured that participants had sufficient time and space to reconsider their participation. After the
second verbal consent was given, the researcher scheduled an interview appointment with the participant. Inpatients who agreed to the study were interviewed after they were discharged. Written consent was obtained from all participants before the start of the interviews. As the communication styles of individuals in Asian cultures differ substantially from Western cultures, one-to-one interviews were preferred over focus group discussions
[39]. To minimize the possibility that participants may describe their illness beliefs in medical terms, the interviews were carried out at the research interview rooms which were situated away from the clinical setting in IMH. Only one interview was conducted outside of the hospital at the convenience of the participant. To minimize the potential lack of cultural
sensitivity that may present itself during the interviews, interviewees were matched with interviewers according to ethnicity as much as possible. An interview schedule (S1 File) that covered questions on the depression experience and culture was used. Interviews were conducted primarily in English; however, as participants were bilingual, they were encouraged to converse
in their mother tongue languages if they felt more comfortable doing so. Interviews were audio-recorded and transcribed verbatim in both English and mother tongue languages (Chinese/Malay/Tamil) which were translated in the same transcript. Interviews lasted approximately 1 hour and 3 minutes on average, and the duration of the interviews ranged from approximately 33 minutes to 2 hours. This study was approved by the local institutional ethics and review boards: the Domain
Specific Review Board (DSRB) of the National Health Group (NHG) and the Institutional Research Review Committee (IRRC) in IMH. A total of 52 individuals were approached from February 2018 to January 2019. Fourteen of those approached had refused to participate or were uncontactable when re-contacted. Most individuals did not cite any reason for refusing, while some others mentioned that they were uninterested, busy, or
uncomfortable with the study’s interview format. Individuals signed written informed consent forms before the start of the interviews. Diagnoses were initially based on self-report or by a referring clinician (NS, who knew the inclusion and exclusion criteria for this study) and were only verified after the completion of the study with their electronic medical records (upon getting written consent to do so) or their doctors. Four participants were withdrawn as they did not fulfil the eligibility
criteria. Thus, a total of 34 individuals (19 females and 15 males) with depressive disorders completed the interviews. Subsequently, one transcript was excluded from the analysis as it differed substantially from the rest of the transcripts (participant’s illness beliefs were primarily associated with another medical condition), leaving a final count of 33 transcripts. Participants were purposively sampled to ensure adequate representation by ethnic groups. Data reached saturation after 12
Chinese, 11 Malay, and 9 Indian participants were interviewed. Although one participant was Sri Lankan, she had been living in Singapore most of her life. Her narrative met with great familiarity and was analysed with the rest of the transcripts. The average age was 26 years old and ranged from 20 to 35 years old at the point of the interview. Participants were on average living with depressive disorders for approximately 3.7 years, ranging from 4 months to 16 years. In terms of highest
educational qualifications attained, 12 participants had pre-university or secondary school qualifications and 21 participants had a diploma, university degree, or vocational qualifications. All of the participant characteristics are summarized in Table 1. Self-reported participant characteristics and sociodemographic information (n = 33).
AnalysisWe chose to analyse the transcripts with thematic analysis described by Clarke and Braun [40, 41] because of the advantages it offers to researchers working in the healthcare setting. Thematic analysis allows researchers in healthcare to overcome methodological constraints, such as a lack of time, resources, and expertise that are required for many other qualitative approaches. The authors (WLT, ES, LC, RK, FD, SS) are all quantitative researchers by formal training (i.e., degrees in psychology/sociology at least), have all been trained in qualitative research, and are experienced in the use of thematic analysis. The initial coding process involved conducting open coding of each sentence in each transcript [42, 43]. The first author utilized deductive (themes of CSM were determined a priori) and inductive (from ground up) coding simultaneously throughout the coding process using the framework described by Feredey and Muir-Cochrane in 2006 [44]. Inductive coding involved recognizing, identifying, and clustering of important information that represented aspects of a phenomenon. On the other hand, deductive coding involved using pre-existing codes as a guide and template for the clustering of information. Transcripts were analysed using the Nvivo software. All transcripts were analysed thematically by the first author (WLT) to determine if 1) data reached theoretical saturation for each ethnic group and if 2) there were new emergent codes or themes. The initial process of coding started at the midpoint of the study as interviews were being conducted. Transcripts were initially analysed by ethnicity, but as the preliminary themes did not differ substantially between ethnic groups, transcripts were eventually analysed as a whole. A codebook that comprised of the codes and its’ definitions was reviewed and analysed iteratively through multiple discussions between the team members (WLT, ES, LC, RK, FD, SS) until a high inter-rater agreement of 0.73 (Kappa) was achieved. Co-author MS provided advice and guidance over the study design, procedures, and analyses of the study. Interviews ceased when no new information, codes, or themes emerged from the interviews that could change the codebook, in other words, data had reached theoretical saturation [43]. The first author also wrote memos detailing her immediate thoughts of possible links to theoretical concepts during the entire thematic process, which were later discussed alongside the review of the codebook with team members. ResultsThe themes that emerged were generally in accordance with the CSM as determined a priori. However, additional themes emerged from inductive coding which were separate from the concept of CSM. In summary, five major themes emerged: 1) A reduced state of being experienced at a point of goal disengagement, 2) The accumulation of chronic stressors in a system that demands success and discourages the pursuit of personally meaningful goals, 3) A wide range of symptoms that are uncontrollable and disabling, 4) Poor decision making resulting in wasted opportunities, with some positive takeaways, and 5) Accepting the chronicity of depression. 1. A reduced state of being experienced at a point of goal disengagement1.1 At a point of disengagement of existing (unattainable) goalsDepression was likened to “a stop button in my life.” It was experienced as a point of change or disengagement from the lack of achievement of existing goals and expectations.
It manifested cognitively as a lack of direction (i.e., feeling lost and stuck) and motivation (i.e., having no point in life), and affectively as frustration and discontentment.
1.2. An entity that is separate or a part of the selfDepression was described to be associated with the self in two ways. First, depression was seen as a separate entity that endangered the sense of self. Some participants were constantly battling depression in their minds, preventing it from encroaching into their sense of selves. Experiencing a depressive episode was thus seen as being powerless over the hold that depression had over them which they depicted as an indomitable force.
Depression had a lasting impact on self-identity. Over time, it displaced the self.
Second, depression was seen as part of the self by some participants, primarily as an emotion that everyone experiences in varying degrees.
As these participants perceived symptoms of depression to be universally present, the meaning of “having depression” had more to do with taking on the medical label rather than the presence of it.
Reactions to the medical label were mixed. Being clinically diagnosed was reassuring as the feelings that they had been dealing with for a long period of time were legitimized, yet at the same time, there was a sense of guilt as having the medical label provided a justification for a lack of ‘control’ over these symptoms.
1.3. A reduced state of beingRegardless of whether depression was seen as separate from or as a part of the self, participants generally believed that a depressive episode was a reduced state of being that eventuated from a depletion of cognitive resources that were used to deal with external (i.e., environmental or social) afflictions which was usually narrated to be chronic in nature. In other words, depression is experienced when the mind was no longer “strong enough” to withstand periods of accumulated stress.
2. The accumulation of chronic stressors in a system that demands success and discourages the pursuit of personally meaningful goals2.1. Causes are multi-faceted and often chronic in natureWhile participants acknowledged that there are multiple biological, environmental, and social causes, which could interact and lead to depression, participants reiterated that a large part of it was due to an accumulation of chronic environmental or social stressors. Family was frequently seen as a main source of stress, conflict, instability, and abuse which panned out over a long period of time.
As a result of the chronic lack of warmth and closeness with the family, some individuals became heavily and emotionally invested in relationships with significant others. Unfortunately, when these relationships dissolved, it became overwhelming, triggering episodes of depression.
Additionally, work and school were cited as common sources of stress. Individuals were expected to perform or conform to a strict and highly pressured work culture or were overwhelmed by the demands of school. The inability to leave the chronic stressor (i.e., “They don’t have a choice”) and the lack of timely resolution was perceived to lead to an accumulation of stress past a threshold and into depression.
2.2. High societal expectations of successThe “chase of achievements” or being an “overachiever” at school or work is a societal expectation and a norm that is instilled in the family since young. It is the “system that demands that I do well” (C11/22/M). This mentality was seen as damaging and was believed to be a main contributor of depression for some. Much of the content in negative thinking (i.e., feeling useless, shame) appeared to be associated with the lack of accomplishment.
2.3. Unable to pursue personal goals that are incongruent with familial and societal expectationsAccording to some participants, depression was experienced when they felt they had failed to reach their goals. Living up to high familial/societal expectations was difficult, yet switching to goals that were personally more meaningful was not seen as an option for many. Not being able to define and pursue personal goals, especially goals that were incongruent with the expectations of the family or society, were articulated as a contributor to depression. The lack of agency in influencing the direction of their future that is personally meaningful left them feeling demotivated and trapped at the same time.
3. A wide range of symptoms that are uncontrollable and disablingParticipants mentioned somatic, psychological, cognitive, and emotional symptoms as indicators of depression that were disabling in nature. Participants cited somatic symptoms most often. These symptoms included sleeping issues such as insomnia, hypersomnia, low appetite, low energy, fatigue, or migraines. Behavioural symptoms such as self-harm and attempted suicide were also mentioned but less frequently.
In addition to behavioural and somatic symptoms, participants commonly cited cognitive symptoms. The two types of cognitive symptoms that were typically present in the narratives: 1) Cognitive symptoms that were overly active, uncontrollable, and intrusive (i.e. rumination or catastrophic thinking), and 2) cognitive aspects which were absent or reduced (i.e. lacking motivation, lacking concentration, helplessness or hopelessness).
Participants described psychological and emotional symptoms as well, such as feeling sad, crying, anxiety and hallucinations, but were mentioned less frequently. 4. Poor decision making resulting in wasted opportunities, with some positive takeawaysFor the majority of participants, depression had a negative impact on their general and social functioning, and school or work performances. In addition, some participants recounted making poor decisions on key instances which adversely affected their future outlook. 4.1. Consequences from poor decision making and wasted opportunitiesSeveral participants felt that because of depression, they held themselves back from key opportunities that would otherwise improve future prospects if they had seized them. Interestingly, not being able to take on opportunities was indicative of being separate from normal.
4.2. Positive consequencesContrastingly, a few participants believed that there were positive consequences. One participant believed depression gave her a sense of empathy and advocacy for others with mental illnesses.
5. Accepting the chronic nature of depressionParticipants had initially believed that depression was an acute condition that could be cured within a short amount of time but most have come to accept that depression is a chronic condition, and the route to recovery is long and arduous.
Depression was likened to cancer. The majority of participants did not believe that depression could be eradicated completely or that they could be fully cured of its symptoms (i.e. “Not a hundred percent curable”). Depression could be managed or treated but the chance of relapse was thought of as highly likely due to unforeseen stressors that may crop up in the future.
From the narratives, depression was thought of cognitively as an entity that may be a part of or separate from the self. Regardless of cognitive representations, depression was primarily experienced as a reduced state of being that occurred as a result of a depletion of resources to cope with unresolved and often chronic stressors. Such chronic stressors typically comprised having to deal with prolonged periods of strained relations with the family, or demands from school or work. Having depression meant making poor decisions on key instances which participants perceived to have had profound long-term consequences. Further, depression was seen as a chronic condition with no means of a full recovery. Over and beyond these aspects of cognitive representations was the emergence of themes surrounding goal disengagement and re-engagement which was unique to the present narratives. DiscussionThis study aimed to explore illness perceptions in young adults with depressive disorders in Singapore. The themes that emerged from this study were to an extent similar to past literature supporting the claim that the CSM has its limits in modelling the way individuals perceive mental illnesses due to added dimensions associated with the self [12, 14]. Along with these results, there were also emergent themes that were unique to depressive disorders which will be discussed at greater length in the present section. Depression, self-identity, and goal disengagementBased on the themes that emerged from inductive open coding, depression was highly associated with the self and self-concepts. Our findings support the notion that there might be an added dimension of illness perception regarding the extent to which the condition is seen as a part of or separate from the self [20], and could reflect differing levels of conflict or acceptance during identity reconstruction [45, 46]. Unlike physical illnesses, which are almost always appraised as unwanted external afflictions to the body, individuals may or may not see depressive disorders in the same regard. When individuals were asked what depression meant to them, they generally described it as a psychological entity that was either separate from or a part of the self, which is consistent with past reports that investigated illness perceptions in individuals with severe types of mental illnesses [13, 14, 17, 19, 20]. Due to the realization that depression is a chronic condition with no means of full recovery, young adults saw themselves grappling with identity changes manifesting within the self [46]. Regardless, episodes of depression were often described as a reduced state of being from their normal selves. This experience of depression is similar to that found in a qualitative study by Kinderman et al. among individuals with psychosis, where episodes were considered to be “periods of socially recognized states of altered psychological functioning” [13]. However, there is a difference. According to participants, a reduced state of being was experienced as a result of a depletion of cognitive resources required to cope with the accumulation of unresolved and often chronic stressors, which is vastly different from being simply in an altered state of irrationality described by individuals with psychosis [13]. Finally, similar to past reports, depression is not always appraised as negative [19, 20]. Having depression gave new meaning and perspectives (e.g., advocacy, empathy) into the lives of a few participants. From our findings, conflicts in self-identity are central to the experiences of depression. Constructivist theorists have posited that individuals experience implicative dilemmas, defined as a type of cognitive dissonance that arises whenever a desired change in a self-concept clashes with a system’s worldview, on which such a change is undesired [47]. Conflicts within self-concepts in relation to goal reconstruction seem to reflect a struggle to satisfy society’s desired ideals alongside personal aspirations. Even though Singapore is often lauded as a melting pot of eastern and western cultures, the family is fundamentally collectivistic in nature. Mainstream ideals of success that are propagated from Chinese influences (the majority ethnic group) are inculcated in the family and in school. Capitalistic values of competitiveness and meritocracy, fuelled by the need to survive as a nation since the industrial era, are entrenched in the cultural fabric of Singapore [48]. From a young age, individuals are taught at home and in school to be successful and to be a useful member of society; life’s happiness is contingent on a person’s level of contribution to society which is measured by achievements and social standing. The majority of young adults recalled feeling that they were under tremendous pressure to fulfil unrealistic ideals [49] originating from the family [50]. Additionally, at least relevant for the current sample, this pressure was contributed by an achievement-focused mind-set that was heavily instilled from a young age, and consistently reminded in schools and workplaces which demand excellence and uncompromised productivity. Participants described this mind-set to be detrimental when goals became unattainable; the pressure to succeed at such goals in a system that demands success, could have contributed to the rise of more severe forms of depression [51, 52]. The perceived inability to re-engage new and personally meaningful goals could have further exacerbated and prolonged symptoms of depression past a clinical threshold [53, 54]. Moreover, it was evident that the difficulties surrounding goal re-engagement were partly due to the fear of negative social ramifications (e.g., shame, conflict, social exclusion), as the expectations of the family are almost non-negotiable in typical Asian families [55, 56]. Contemplating to reconstruct personally meaningful goals that may go against society’s ideal expectations of success seem to parallel a clash of worldviews, which in turn, can create high levels of conflict within the self [47]. Coping with goal failure is one aspect that is rarely discussed among clinical populations [51, 52]. The link between goal disengagement/engagement and the depression experience found in this study would thus warrant future research into this phenomenon. Cognitive paradigms suggest that depression can be improved by addressing the negative cognitive triad (negative view of the self, the world, and the future) in therapy [57]. Consequently, dilemma-focused therapy is as beneficial as Cognitive Behavioural Therapy (CBT) in ameliorating symptoms of depression [58]. Our results support the notion that addressing implicative dilemmas in addition to negative cognitive self-concepts is important and greatly relevant culturally for the recovery of depression in young adults in Singapore [59]. Given that the average onset of depression lies in the period of young adulthood [60], which is also a crucial period of psychosocial development that includes identity formation, self-development, and achievement goal orientations [61–65], the temporal overlap with such crucial developmental period further exacerbates the need to understand the role of culture and family in goal reconstruction in young adulthood. Discussing cultural expectations of success with the family in therapy would thus be beneficial for young adults with depression locally. Depression illness beliefs in a multi-ethnic non-western societyCulture was initially assumed in this study as static and pre-defined identities that tie closely to ethnicity (i.e. Chinese/Malay/Indian cultures). However, the similarities in narratives across ethnic groups reflect a different definition of culture, or macro-culture, defined as how individuals actively make sense of their lives and illness through common experiences regardless of ethnic background [66]. Illness perceptions of depressive disorders were generally similar across Chinese, Malay, and Indian ethnic groups, and to that of the West [17, 18, 67]. Perhaps due to the sample’s young adult makeup that consisted of a highly educated majority (67% of participants had a diploma or university degrees), causal beliefs were neither overwhelmingly spiritual nor traditional but were highly similar to themes reported in the extant literature that also had a strong emphasis on socio-environmental and psychosocial causes [13, 18, 20, 68]. This was accompanied by a preponderance of the belief that a relapse was strongly dependent on unforeseen future socio-environmental triggers that could potentially provoke future episodes of depression. Collectively, such beliefs are noteworthy as two inferences can be derived. First, even as young adult patients sought biomedical interventions, such as pharmacotherapy, they were perceived to work primarily as a temporary relief of symptoms rather than a panacea to rid the condition altogether [13]. Second, it is perceived that the root of the depression lies in the disharmony of the self within the system, and therefore, it cannot be fully addressed by engaging either one part in isolation. Recovery of depression should be approached by addressing both cultural and biopsychosocial factors in an integrated fashion. An integrated approach should be emphasized as the country gains momentum in reshaping its healthcare system towards one that is patient centred. While young adults do benefit from clinical interventions, their narratives paint a broader picture of how limiting these interventions may be without considering the sociocultural context. Depression means to be in a reduced state of being, which is a frame of mind of living a less than meaningful life, characterised by a struggle to reconcile intersubjective misalignments [69] that threatens self-identity and autonomy. Recovery thus not only involves a return to premorbid health but also involves the process of regaining control over one’s agency, goals, and aspirations [70]. Our findings further support the notion that depression is caused (in part) by the strained relationship between the self and the social environment [45]. Therefore. regaining control over goals would therefore require the recognition and support from the immediate social environment [69, 71], on which a young self-identity can continually be validated and fostered. This study is not without limitations. First, some of the participants were undergoing treatment and/or therapy at the time of the interview and it is unclear how much of illness beliefs were a result of psychoeducation. Second, we recruited young adults who were willing and able to sit through an interview. It is possible that those who refused the study, especially those who had cited that they did not feel comfortable with the interview format, may have different illness experiences. Thus, illness beliefs found in this study may differ from those who are not undergoing formal treatment or who refused the study. On the surface, young adults’ illness representations of depression have struck a chord with past literature. Careful thematic explication revealed important sociocultural nuances that were unique to the current context. Young adults reportedly faced tremendous pressure to fulfil unrealistic societal expectations and had consequently struggled to construct personally meaningful goals. Depression is thus a frame of mind of living a less than meaningful life, which at a latent level, represented an underlying struggle of addressing implicative dilemmas that represent a clash of personal and cultural worldviews. These findings re-emphasized the role of culture in illness perceptions of depression and self-identity. Addressing societal and familial expectations in relation to goal failure would therefore have immense relevance for young adult individuals seeking psychotherapy in Singapore. Supporting informationS1 FileInterview schedule. (DOCX) Funding StatementThis research is supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (Grant No.: NMRC/CG/M002/2017_IMH). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data AvailabilityWe have indicated that the data for this study is available upon request. The restriction is imposed by our institutional and ethics committee. Data can only be shared after a proposal is approved by the ethics committee. This has also been conveyed to our participants during the consent process. 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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ********** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ********** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This paper presents an original qualitative research on illness perceptions in young adults diagnosed with depressive disorders based on an Asian context (Singapour). Overall, the topic is highly relevant for psychology and the qualitative perspective s most appropriate to explore narratives to understand the lived experience of people with depressive disorders. The paper is well-structured and the English is correct. Despite these qualities, the current version of the paper calls for substantial changes at epistemological, theoretical and methodological levels in order to be potentially ready for publication in PLOS ONE, especially given the solid and high quality of this journal. Here below my suggestions to improve the quality of the present version of the manuscript: 1) Introduction: The Leventhal model is presented in the introductory part as a core theoretical perspective mobilized by the authors, as they position themselves critically towards such model. However, the reader wonders why, given the broad body of qualitative research on depression, the introduction is narrowed down to research on this model? What about other qualitative approaches to depression, that also take into account narratives on illness (ex. phenomenology and IPA, narrative, discursive...). I very much appreciated that you mention the role of culture as it shapes the experience of illness - This is an inherent part of the socio-constructionist perspective namely. But scientific references are missing to better argue on the crucial role of culture (understood as a set of norms and values - giving rise to social narratives that contribute to determine how we experience the world and ourselves). The distinction between West and East remains rather superficial and broad. What seems specific to the context you chose for your research and why is it relevant for the hypothesis that you raise at the end of this section? Furthermore, while narratives seem the crucial focus on this paper, the reader cannot really grasp from the manuscript's content why the narrative focus is so important. As a qualitative researcher in psychology, I personally fully agree with you on the central role of narratives. But why are narratives so important? Different perspectives have been developed within psychology, namely that of structuring our sense of selves and our world (discursive, constructionist, narrative), but also that of making sense of our experience (for example, phenomenology). However, the choices underlying your theoretical approach seem absent /scarcely developed. Indeed, there are multiple approaches to narratives - and this theoretical foundation is currently missing from your paper. The problematisation at the end of the introduction falls short: why the hypothesis on the sense of self? Can you develop what you mean by this and argue with additional references to make your research/theoretical posture more explicit? 2) Methodology: To me, this section requires important changes. Under the 'procedure' paragraph, the population is already mentioned but then you come back to participants in the next paragraph entitled 'participants' - The reader can be a bit lost in this order. I would suggest to better justify the qualitative approach used in the 'procedure' paragraph to better explain the whole methodological procedure in a general way. line 119: what do you mean by 'subconsciously'? not appropriate from my perspective - better explain your decision on the context of the interviews In the population paragraph, the average age needs to be better justified - (especially if 'young adults' is part of your title - why young adults rather than older adults? Also, there is no mention of the gender except for the number of male and female - but according to me, the 'gender' dimension needs to be at least considered and justified to increase methodological rigor - as in depression this seems to play an important role (ex. constructions of masculinity/feminity) Also, on the interview description - there is no information on the interview guide nor how it was elaborated. This is an important aspect to better understand how the analysis were conducted afterwards, in the analytical phase. Regarding the 'analysis' section - practically no scientific references are used to justify your analysis technique. Yet, this methodological stage is particularly important. I would suggest reading Virginia Braun and Victoria Clarke who have extensively written on thematic content analysis. Line 144: Saturation? Better explain and use scientific reference (This notion is contested in qualitative research depending on the authors). Line 158: open and ground coding - what does this mean? Reference please 3) Results: The themes are very general - A 'good' theme definition is that which captures in its name the full condensed 'story' or 'message' that the given set of data portrays. Moreover, please restructure with numbers or letters in hierarchical order the different themes and subthemes as it is difficult for the reader to follow. I regret that there is a lot of 'verbatim' that illustrate the names of your subthemes but little explanation or interpretation on what these themes and subthemes mean in relation to your hypothesis and research aim. At times, the text is written as if narratives 'reflected' a 'truth' or a 'reality' - Please keep in mind what status do narratives have in your theoretical perspective to better guide you on how to write about them. I sometimes disagreed with the authors' explanation on certain quotes - to me, Line 200 for instance, would call for a separation between mind and body rather than depression as a different entity, from what I understand from the participants' verbatim Often, authors refer to results as 'they' (participants') as if all participants had positioned themselves in an homogeneous way regarding their experience. Were there any dissident narratives for example? Line 286: while this seems a key theme (or subtheme?) it is very little developed/explained. Line 315: spelling of 'yeah' Line 352: This theme follows a hierarchical numeration while the rest of the themes do not. In the end of the result section, a synthesis of results would be very useful. Discussion: Coming back to the CSM model - why and how it was confirmed? Why do authors overlook the similarities of their results with the model (if it's an important focus of the paper)? Line 428 'are under pressure' - this is a strong affirmation that is different from 'perceive themselves as being under strong pressure' for example. This study is qualitative so it takes the subjective constructions into account - not revealing an 'objective' reality. Line 474: regarding the limitations, please consider that the aim of qualitative research is not generalization but on the contrary, considering variablity, contextualization, narratives, singularity, experience - therefore it is not a limitation from my view. Finally, how can your conclusions be extended beyond the Leventhal model and contribute to psychology more broadly? This could be a stronger case if your theoretical position/framework were better made explicit in the introduction for example. Reviewer #2: Thank you for asking me to review this manuscript. This qualitative inquiry aimed to explore the illness perceptions of Chinese, Malay, and Indian young adults diagnosed with depressive disorders by using one-to one face-to-face semi-structured interviews. They concluded that depression was typically experienced as a reduced state of being, and was thought of cognitively as an entity that may be a part of or separate from the self. Five themes were identified as: 1) meanings, 2) causes, 3) symptoms, 4) consequences, and 5) chronicity of depression. Such an effort could be valuable for cultural diversity and future implication. The following issues need to be considered: 1. In abstract, the research purpose is expected to be added. 2. In abstract, Conclusion-“Depression was typically experienced as a reduced state of being, and was thought of cognitively as an entity that may be a part of or separate from the self. .. the results emphasized the importance of examining self concepts in therapy and recovery.…” Such a conclusion might be relevant to young adults’ developmental task at their developmental stage? It might not be applicable for other groups at different ages? 3. In Introduction, please add the rationale why selecting the young adults as a target? Relevant research significance would be helpful, eg; What’s the global prevalence of major depression in young-aged papulation? 4. The positive aspects of the illness perception were mentioned from several literatures (Line 48-57). Please compare your results with previous studies in Discussion. 5. In Method, Line121-More clear information is needed, for example: interviewees’ qualification and training? Were interview process standardized or using the identical interview guidelines? What contents of interview guidelines included? Or how did you achieve the same focus of the interview contents? 6. How could the researcher prevent yourselves to be influenced or guided by these prior understanding? For example, the existing knowledge on the Common-sense Model of Self-Regulation (CSM) by Leventhal. Was the interview guideline or analytical coding process followed by the CSM theory? 7. Line144-150, please add the Standardized Deviation following the mean to indicate the variation and range of the sample characteristics. Most are single, please report the %. 8. Line148, 6 participants live with depressive disorders lower than 1 year, with a mean of 3.5 years, and the least was 4 months. How will it influence your results? It might be some limitation. 9. About the analysis, in Line 145-146- How was the transcript of one individual from Sri Lankan analyzed with the rest of the transcripts as a whole? 10. In Results, it’s not easy to distinguish the “themes” and “sub-themes”. Please clearly separate the “5-themes” and “sub-themes” to increase the readability. 11. Among all themes identified as cognitive representations, I’m wondering was there any emotional perspective or anything related to their coping or management with the mood symptoms while looking at their illness ration than cognitive aspects? 12. Line 356, “3.4.1…”? 13. Table—what’s the meaning of the 「^」 following the number, eg: 2^ or 7^? ********** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Maria del Rio Carral Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at gro.solp@serugif. Please note that Supporting Information files do not need this step. Author response to Decision Letter 025 Nov 2020 18 November 2020 RE: Responses to reviewers Dear Reviewers, We thank you for taking the time to review our manuscript. We have learnt a lot from the peer review process and have incorporated your comments in our next draft. Please find our point-by-point responses to the comments in the boxed text area below: Reviewer #1: This paper presents an original qualitative research on illness perceptions in young adults diagnosed with depressive disorders based on an Asian context (Singapour). Overall, the topic is highly relevant for psychology and the qualitative perspective s most appropriate to explore narratives to understand the lived experience of people with depressive disorders. The paper is well-structured and the English is correct. Despite these qualities, the current version of the paper calls for substantial changes at epistemological, theoretical and methodological levels in order to be potentially ready for publication in PLOS ONE, especially given the solid and high quality of this journal. Here below my suggestions to improve the quality of the present version of the manuscript: 1) Introduction: The Leventhal model is presented in the introductory part as a core theoretical perspective mobilized by the authors, as they position themselves critically towards such model. However, the reader wonders why, given the broad body of qualitative research on depression, the introduction is narrowed down to research on this model? What about other qualitative approaches to depression, that also take into account narratives on illness (ex. phenomenology and IPA, narrative, discursive...). Answer: Thank you for this. We agree with the reviewer that more could be elaborated on this point. There are important reasons for using Leventhal’s model. Firstly, the Leventhal model is one of the most widely used model due to its good psychometric properties, to predict self-care behaviours and recovery in physical illnesses. Secondly, unlike other health belief models, this model comprises of emotional illness representations, which are directly relevant to mental illnesses. We have elaborated on this point in the subsequent draft. We agree that there are many other qualitative approaches that are highly relevant to the study of narratives. For instance, IPA is very useful in providing rich accounts of the depression experience. However, as it had been previously discussed by Braun and Clarke (2020) and Chamberlain (2012), there is no one ideal or superior qualitative method. The choice of method may also be dependent on pragmatic factors as well- we are unfortunately limited in our access to resources and are facing time constraints. Finally, authors (and coders of this study) are experienced and trained in thematic analysis only. We wish to be able to use other qualitative approaches in the near future because of its relevance in the work that we do. We agree with the reviewer that this was insufficiently justified in the manuscript and have made substantial edits to it. I very much appreciated that you mention the role of culture as it shapes the experience of illness - This is an inherent part of the socio-constructionist perspective namely. But scientific references are missing to better argue on the crucial role of culture (understood as a set of norms and values - giving rise to social narratives that contribute to determine how we experience the world and ourselves). The distinction between West and East remains rather superficial and broad. What seems specific to the context you chose for your research and why is it relevant for the hypothesis that you raise at the end of this section? Answer: Thank you for this. As the reviewer had succinctly pointed out, the illness experience of an individual may be influenced by societal norms and values. We agree fully with the reviewer that this portion is underdeveloped in the present draft, and have since made changes in the subsequent draft. Furthermore, while narratives seem the crucial focus on this paper, the reader cannot really grasp from the manuscript's content why the narrative focus is so important. As a qualitative researcher in psychology, I personally fully agree with you on the central role of narratives. But why are narratives so important? Different perspectives have been developed within psychology, namely that of structuring our sense of selves and our world (discursive, constructionist, narrative), but also that of making sense of our experience (for example, phenomenology). However, the choices underlying your theoretical approach seem absent /scarcely developed. Indeed, there are multiple approaches to narratives - and this theoretical foundation is currently missing from your paper. The problematisation at the end of the introduction falls short: why the hypothesis on the sense of self? Can you develop what you mean by this and argue with additional references to make your research/theoretical posture more explicit? Answer: As quantitative researchers by training, we are largely unfamiliar with the theoretical concepts that are widely used in sociology. However, social constructivism, as we recognize, is highly relevant to our study. Thus, we understand and agree fully with the reviewer that the introduction can be improved further by laying theoretical grounds for the study and we hope the subsequent draft reads better. We thank the reviewer for these suggestions. 2) Methodology: To me, this section requires important changes. Under the 'procedure' paragraph, the population is already mentioned but then you come back to participants in the next paragraph entitled 'participants' - The reader can be a bit lost in this order. I would suggest to better justify the qualitative approach used in the 'procedure' paragraph to better explain the whole methodological procedure in a general way. line 119: what do you mean by 'subconsciously'? not appropriate from my perspective - better explain your decision on the context of the interviews Answer: Thank you for this. The main reason for carrying out the interviews away from the clinical setting was to prevent contextual priming at a subconscious level that may influence the way participants describe their illness experience clinically during the interviews. We have rephrased this explanation and restructured the paragraphs. In the population paragraph, the average age needs to be better justified - (especially if 'young adults' is part of your title - why young adults rather than older adults? Also, there is no mention of the gender except for the number of male and female - but according to me, the 'gender' dimension needs to be at least considered and justified to increase methodological rigor - as in depression this seems to play an important role (ex. constructions of masculinity/feminity) Answer: Major Depressive Disorder is the most prevalent mental illness among young adults aged 18 to 34 years old (Subramaniam et al., 2020), thus, these narratives describe how depression is typically experienced at the onset for this age group. Understanding how illness is experienced among young adults would be important for treatment and recovery that is also relevant for this age group. Before the start of the study, researchers conducted a literature review of illness perception of severe mental illnesses. As reported in the introduction, the primary themes that emerged were related to the self, with no prominent mentions of gender. During the coding and analyses phase, the first author did suspect possible cultural influences on the role of gender. For instance, the theme “High societal expectations of success”, initially emerged from the narratives of male participants. This was detailed in her memo, indicating that instances like this could demonstrate cultural expectations of the need to succeed being more salient in men. However, during the course of coding, this theme was prominent in female participants as well. While we agree with the reviewer that gender does play an important role, it did not emerge during the literature review and analyses. Also, on the interview description - there is no information on the interview guide nor how it was elaborated. This is an important aspect to better understand how the analysis were conducted afterwards, in the analytical phase. Answer: Thank you for this, the interview guide has been attached as supporting information in the subsequent submission. Regarding the 'analysis' section - practically no scientific references are used to justify your analysis technique. Yet, this methodological stage is particularly important. I would suggest reading Virginia Braun and Victoria Clarke who have extensively written on thematic content analysis. Line 144: Saturation? Better explain and use scientific reference (This notion is contested in qualitative research depending on the authors). Line 158: open and ground coding - what does this mean? Reference please Answer: Thank you for this. We recognize that this is important but was mistakenly left out. We have uploaded the interview schedule in its final form. We have also improved on the analysis section to explain our sampling and analysis technique, including scientific references to support our justifications. 3) Results: The themes are very general - A 'good' theme definition is that which captures in its name the full condensed 'story' or 'message' that the given set of data portrays. Moreover, please restructure with numbers or letters in hierarchical order the different themes and subthemes as it is difficult for the reader to follow. I regret that there is a lot of 'verbatim' that illustrate the names of your subthemes but little explanation or interpretation on what these themes and subthemes mean in relation to your hypothesis and research aim. At times, the text is written as if narratives 'reflected' a 'truth' or a 'reality' - Please keep in mind what status do narratives have in your theoretical perspective to better guide you on how to write about them. Answer: Thank you for the suggestions. We have made additional changes to the name of the themes/subthemes to better represent the themes that emerged from the narratives. I sometimes disagreed with the authors' explanation on certain quotes - to me, Line 200 for instance, would call for a separation between mind and body rather than depression as a different entity, from what I understand from the participants' verbatim The verbatim quote may not have clearly captured the context. What we had understood from the participant during the interview was that “…the thing is in your mind. So [the thing in] the mind is taking over your body…” M11/31/F/M Often, authors refer to results as 'they' (participants') as if all participants had positioned themselves in an homogeneous way regarding their experience. Were there any dissident narratives for example? Answer: Thank you for this. Only the prominent themes were reported in the manuscript. The prominence of themes was not necessarily dependent on the majority although it was primarily so, and we would have stated if the themes or codes emerged only from a few. For instance, the narrative that depression is separate from or a part of the self, came from two different groups of participants, which we had merged to form a subtheme. We did encounter dissident narratives, for instance, narratives like, “depression comes from the brain so I think to actually rewire something takes a long time M12/26/F”, or “depression is something that’s very, very repetitive C12/22/F”, but we did not report as it was decided among coders that they were not prominent codes. Line 286: while this seems a key theme (or subtheme?) it is very little developed/explained. Line 315: spelling of 'yeah' Line 352: This theme follows a hierarchical numeration while the rest of the themes do not. In the end of the result section, a synthesis of results would be very useful. Answer: Thanks for highlighting as these were mistakes. We have edited/removed them in the subsequent draft. The format of the manuscript has changed, and we hope it will read better. Discussion: Coming back to the CSM model - why and how it was confirmed? Why do authors overlook the similarities of their results with the model (if it's an important focus of the paper)? Thank you for this. The main objective of the study is to understand illness perceptions of depressive disorders, and it was not to disprove or confirm the CSM model. We had however, made few concluding statements as our study provided support for the conclusion that the CSM may be overly simplistic, although it is a useful guide for mental illnesses. Line 428 'are under pressure' - this is a strong affirmation that is different from 'perceive themselves as being under strong pressure' for example. This study is qualitative so it takes the subjective constructions into account - not revealing an 'objective' reality. Line 474: regarding the limitations, please consider that the aim of qualitative research is not generalization but on the contrary, considering variablity, contextualization, narratives, singularity, experience - therefore it is not a limitation from my view. Answer: We agree with the reviewer and had removed this statement from limitations. We thank the reviewer for this important point. Finally, how can your conclusions be extended beyond the Leventhal model and contribute to psychology more broadly? This could be a stronger case if your theoretical position/framework were better made explicit in the introduction for example. Answer: The themes that emerged in this study were highly associated with the self, emphasizing the importance of self-concepts, such as self-agency, goals, sense of meaning and belonging, in the study of illness perceptions of severe mental illnesses. Additionally, our results evidently show that personal recovery requires the consideration of cultural beliefs that tie closely to illness beliefs among those surviving with depressive disorders in Singapore. Thank you for taking the time to review this article. We hope the subsequent draft reads better. Reviewer #2: Thank you for asking me to review this manuscript. This qualitative inquiry aimed to explore the illness perceptions of Chinese, Malay, and Indian young adults diagnosed with depressive disorders by using one-to one face-to-face semi-structured interviews. They concluded that depression was typically experienced as a reduced state of being, and was thought of cognitively as an entity that may be a part of or separate from the self. Five themes were identified as: 1) meanings, 2) causes, 3) symptoms, 4) consequences, and 5) chronicity of depression. Such an effort could be valuable for cultural diversity and future implication. The following issues need to be considered: 1. In abstract, the research purpose is expected to be added. Answer: It has been added. We thank the reviewer for spotting this missing point. 2. In abstract, Conclusion-“Depression was typically experienced as a reduced state of being, and was thought of cognitively as an entity that may be a part of or separate from the self. .. the results emphasized the importance of examining self-concepts in therapy and recovery.…” Such a conclusion might be relevant to young adults’ developmental task at their developmental stage? It might not be applicable for other groups at different ages? Answer: Thank you for this. We agree with the reviewer that individuals go through different developmental stages throughout their lives and the conclusion is only relevant to young adults, which is the premise of this study. Major Depressive Disorder is the most prevalent mental illness among young adults aged 18 to 34 years old (Subramaniam et al., 2020), thus, these narratives are descriptive of how depression is typically experienced at the onset for this age group. This aspect of the abstract has been changed to elaborate this point. 3. In Introduction, please add the rationale why selecting the young adults as a target? Relevant research significance would be helpful, eg; What’s the global prevalence of major depression in young-aged papulation? Answer: Thank you for this. Local data reports that the onset of depressive disorders lie within the age range of 18-34 years, thereby making it a relevant age range to target. By understanding how depression is experienced among young adults, it may help to inform treatment and therapy that is relevant for this age group. We agree with the reviewer that this is underdeveloped in the original draft, and have made substantial improvements. We hope the subsequent draft reads better. 4. The positive aspects of the illness perception were mentioned from several literatures (Line 48-57). Please compare your results with previous studies in Discussion. Answer: Thank you for this. Similarly seen in past reports on anorexia nervosa and obsessive compulsive disorder, depression was not always appraised as negative (Higbed & Fox, 2010; Pedley, Bee, Wearden, & Berry, 2019)). Having depression gave new meaning and perspectives (i.e. advocacy, empathy) into the lives of some participants. We agree with the reviewer that this portion should be included in the discussion. 5. In Method, Line121-More clear information is needed, for example: interviewees’ qualification and training? Were interview process standardized or using the identical interview guidelines? What contents of interview guidelines included? Or how did you achieve the same focus of the interview contents? Answer: Thank you for this. The interviewers and coders were trained in thematic analysis conducted by the National University of Singapore (NUS). The interview process was standardized using an interview schedule, which we had left out during the first submission; we have included the interview guide as supporting information in the subsequent draft. 6. How could the researcher prevent yourselves to be influenced or guided by these prior understanding? For example, the existing knowledge on the Common-sense Model of Self-Regulation (CSM) by Leventhal. Was the interview guideline or analytical coding process followed by the CSM theory? Answer: Thank you for this. Before the start of qualitative inquiry, the first author and coders conducted preliminary literature review searches to attain a level of theoretical sensitivity (Mills, Bonner, & Francis, 2006). The interview guide thus follows the CSM theory. 7. Line144-150, please add the Standardized Deviation following the mean to indicate the variation and range of the sample characteristics. Most are single, please report the %. Answer: Thank you for this. We have reported the SD and percentages in the following draft. 8. Line148, 6 participants live with depressive disorders lower than 1 year, with a mean of 3.5 years, and the least was 4 months. How will it influence your results? It might be some limitation. Answer: Thank you for the question. We understand the reviewer’s concerns: an individual who was officially diagnosed just 4 months ago would have a different experience than another who had been officially diagnosed 16 years ago. In this study, outpatients were invited to participate regardless of the length of years diagnosed. We did not put limits on this, as deciphering the exact start points of mental illness (unlike physical illness which are more clear) is difficult unless individuals were followed through a prospective longitudinal study. Furthermore, it is not uncommon for individuals to experience a duration of untreated depression for a good number of years without their awareness, before an official diagnosis is given. Thus, this information may be obscure as well. Finally, we did not find any deviations in narratives of those who lived with depressive disorders for less than 1 year than the rest. 9. About the analysis, in Line 145-146- How was the transcript of one individual from Sri Lankan analyzed with the rest of the transcripts as a whole? Answer: That participant, though Sri Lankan, had mentioned in the interview (and recorded in the transcript) that she had “lived in Singapore most of (her) life”. Her narrative was not substantially different from the rest, and hence, her transcript was analysed as a whole since she did not belong to any of the major ethnic groups. That is, during the meetings between coders, the themes that were coded in her transcript was analysed and reviewed together with the rest of the transcripts while ignoring her Sri Lankan ethnicity. 10. In Results, it’s not easy to distinguish the “themes” and “sub-themes”. Please clearly separate the “5-themes” and “sub-themes” to increase the readability. 11. Among all themes identified as cognitive representations, I’m wondering was there any emotional perspective or anything related to their coping or management with the mood symptoms while looking at their illness ration than cognitive aspects? Answer: Thank you for this, questions on coping methods and management were indeed asked during the interviews (please see the interview schedule). However, we had decided to discuss this portion in a separate manuscript. 12. Line 356, “3.4.1…”? Answer: This was an error. Thank you for spotting this. 13. Table—what’s the meaning of the 「^」 following the number, eg: 2^ or 7^? The symbol “^” denotes self-reported approximate number of years diagnosed with depressive disorder. These participants could not remember the exact year they were diagnosed, hence, the figures reported are a rough estimation. Answer: Thank you very much for taking the time to review this article. -- We hope the subsequent draft reads better and we are open for further discussions and feedback. We hope to hear from you soon and thank you very much again for the time to review our manuscript. Your sincerely, Wen Lin Institute of Mental Health Singapore References cited: Higbed, L., & Fox, J. R. (2010). Illness perceptions in anorexia nervosa: A qualitative investigation. British Journal of Clinical Psychology, 49(3), 307-325. Mills, J., Bonner, A., & Francis, K. (2006). The development of constructivist grounded theory. International journal of qualitative methods, 5(1), 25-35. Pedley, R., Bee, P., Wearden, A., & Berry, K. (2019). Illness perceptions in people with obsessive-compulsive disorder; A qualitative study. PloS One, 14(3), e0213495. Subramaniam, M., Abdin, E., Vaingankar, J., Shafie, S., Chua, B., Sambasivam, R., . . . Chua, H. (2020). Tracking the mental health of a nation: prevalence and correlates of mental disorders in the second Singapore mental health study. Epidemiology Psychiatric Sciences, 1-10. AttachmentSubmitted filename: Response to Reviewers.docx Decision Letter 15 Feb 2021 PONE-D-20-07514R1 A reduced state of being: illness perceptions in young adults diagnosed with depressive disorders PLOS ONE Dear Dr.Teh, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by March 31, 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:
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If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #2: (No Response) ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for responding to my comments. While the new version is substantially better, in my view there are still important aspects that are problematic, from an epistemological point of view. In addition, I still have some concerns on the compatibility of theory (based on a model stemming from a rather cognitive tradition) and methodology (based on understanding of contextualized experiences). Last, the discussion remains too narrow (scientific and practical implications are scarcely discussed). General comment on epistemological concerns The use of qualitative approaches in psychology does not imply the ‘mere’ implementation of interviews + conducting a thematic content analysis, but rather requires an in-depth reflection on how personal experiences are shaped by the social and the cultural, as well as more psychological and embodied aspects. In order to analyse individuals’ experiences, qualitative researches need to de-construct certain presuppositions (e.g. when you state ‘Since illness beliefs are personal in nature’ – this is a very strong assumption that many qualitative psychologists would argue against – as many approaches show how individual experiences and subjectivity – including ‘beliefs’ are socially constructed and therefore contextual – thus the opposite of ‘personal in nature’) Another example of ‘lack of coherence’ between incompatible paradigms is the following statement: “From the perspectives of personality psychology and evolutionary biology, depressive symptoms are adaptive forms of coping that facilitates the detachment of existing unattainable goals to conserve resources which may otherwise further deplete such resources if individuals persisted with such goals (28-30).” This purpose is not coherent with qualitative approaches as it ‘essentialises’ goal setting as if this skill was completely detached from social contexts, social discourses, etc. General comment on the articulation of theory and qualitative methodology As I have tried to explain, qualitative research tradition in psychology stresses the social embeddedness of psychological phenomena. Also, it requires to overcome the risk of methodolatry (see Chamberlain’s paper on this). There shall be more reasons than ‘simply’ practical or resource-related, to justify the use of a method rather than another one. Moreover, the difference that you state between interviews and focus groups is not necessarily true – many authors would argue that this statement “Since illness beliefs are personal in nature one-to-one interviews are preferred over focus group discussions as they provide the space to discuss personal attitudes without being pressured to give socially desirable answers” is not the difference between these two methods at all. As authors admit they come from more quantitative traditions, I would urge them to read qualitative research handbooks on these methods of data collection (and foremost, data analysis methods as they scarcely quote any authors in their analysis technique description) General comment on scientific/broader implications The discussion remains descriptive and too narrow – the reader may ask her/himself ‘so what?’ – what are the implications of studying individual experiences of depression in Singapour? As I had suggested in my previous review, the paper would improve its potential if it could broaden its scope from a theoretical perspective (What do your findings mean for theory on depression (Western-based) and furthermore, what about more practical implications for people who suffer from depression, for healthcare, for psychologists – namely in non Western contexts like Singapour. Reviewer #2: PONE-D-20-07514 A reduced state of being: illness perceptions in young adults diagnosed with depressive disorders Thank you for asking me to secondly review this manuscript. Most of the comments has been well responded, but the following issues still need to be considered to make their effort valuable in cultural diversity and future implication. 1. I’m curious could it be possible that the illness perceptions and experience of your participants have not limited to the CSM framework? The author replied that their interview guide follows the CSM theory, that will easily produce an accordant result with the CSM as their prior framework. How could the researcher prevent yourselves to be mainly influenced by the prior understanding on the existing knowledge on the CSM? 2. The stigma-related issues in non-western society have been mentioned in Discussion; but it has not been reflected from any of patients’ quotations? 3. Please clarify some unclear wordings in Discussion, such as: …that was heavily instilled “from young” at home. …the need to further understand depression in relation to goal failure and coping cannot be better emphasized by the temporal overlap. 4. I appreciate the revision has added more quotations to reveal the cultural significance, for example: “High societal expectations of success”, and “Unable to pursue personal goals that were incongruent with familial and societal expectations”. However, would it possibly relate to the families and the society’s insufficient mental health literacy about depression? It’s suggested to refer existing evidence on the family illness perception and stigma as follows. Please add some related implication as well. Huang CH, Li SM, & Shu BC. Exploring the relationship between illness perceptions and negative emotions in relatives of people with schizophrenia within the context of an affiliate stigma model. J. Nurs. Res 24(3), 217- 223 (2016). Lee, S. K., Lin, E. C. L., Chang, Y. F., Shao, W. C., & Lu, R. B. (2017). Psychometric evaluation of family illness perceptions of patients with schizophrenia. Neuropsychiatry, 7(7), 739-747. ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at gro.solp@serugif. Please note that Supporting Information files do not need this step. AttachmentSubmitted filename: plos one review-20210111.docx Author response to Decision Letter 110 Mar 2021 Dear Reviewers, Thank you for taking the time to review our manuscript the second time. We have incorporated your comments and suggestions in our next draft. In addition, please find our point-by-point responses to your comments in the boxed text area below: -- Reviewer #1: Thank you for responding to my comments. While the new version is substantially better, in my view there are still important aspects that are problematic, from an epistemological point of view. In addition, I still have some concerns on the compatibility of theory (based on a model stemming from a rather cognitive tradition) and methodology (based on understanding of contextualized experiences). Last, the discussion remains too narrow (scientific and practical implications are scarcely discussed). General comment on epistemological concerns The use of qualitative approaches in psychology does not imply the ‘mere’ implementation of interviews + conducting a thematic content analysis, but rather requires an in-depth reflection on how personal experiences are shaped by the social and the cultural, as well as more psychological and embodied aspects. In order to analyse individuals’ experiences, qualitative researches need to de-construct certain presuppositions (e.g. when you state ‘Since illness beliefs are personal in nature’ – this is a very strong assumption that many qualitative psychologists would argue against – as many approaches show how individual experiences and subjectivity – including ‘beliefs’ are socially constructed and therefore contextual – thus the opposite of ‘personal in nature’) Reply: Perhaps a better way to explain is that individuals from collectivistic cultures have different communication styles than individualistic cultures. This has been rewritten in the next draft as we understand the possible conflict it brings theoretically. Another example of ‘lack of coherence’ between incompatible paradigms is the following statement: “From the perspectives of personality psychology and evolutionary biology, depressive symptoms are adaptive forms of coping that facilitates the detachment of existing unattainable goals to conserve resources which may otherwise further deplete such resources if individuals persisted with such goals (28-30).” This purpose is not coherent with qualitative approaches as it ‘essentialises’ goal setting as if this skill was completely detached from social contexts, social discourses, etc. Reply: We agree with the reviewer that this argument is inconsistent with the social constructivist perspective. Therefore, we have removed parts of the discussion section that were incongruent. General comment on the articulation of theory and qualitative methodology As I have tried to explain, qualitative research tradition in psychology stresses the social embeddedness of psychological phenomena. Also, it requires to overcome the risk of methodolatry (see Chamberlain’s paper on this). There shall be more reasons than ‘simply’ practical or resource-related, to justify the use of a method rather than another one. Moreover, the difference that you state between interviews and focus groups is not necessarily true – many authors would argue that this statement “Since illness beliefs are personal in nature one-to-one interviews are preferred over focus group discussions as they provide the space to discuss personal attitudes without being pressured to give socially desirable answers” is not the difference between these two methods at all. As authors admit they come from more quantitative traditions, I would urge them to read qualitative research handbooks on these methods of data collection (and foremost, data analysis methods as they scarcely quote any authors in their analysis technique description) Reply: In the previous and subsequent draft, we had cited Clarke and Braun, as well as the framework documented by Feredey and Muir-Cochrane as our primary texts. The article by Feredey and Muir-Cochrane describes the inductive coding technique by Boyatzis (1998). These are the two main texts that we have cited as we believe they are sufficient to inform and guide our thematic analyses. General comment on scientific/broader implications The discussion remains descriptive and too narrow – the reader may ask her/himself ‘so what?’ – what are the implications of studying individual experiences of depression in Singapour? As I had suggested in my previous review, the paper would improve its potential if it could broaden its scope from a theoretical perspective (What do your findings mean for theory on depression (Western-based) and furthermore, what about more practical implications for people who suffer from depression, for healthcare, for psychologists – namely in non-Western contexts like Singapour. Reply: The discussion section has been revised extensively on this aspect as we agree it is still lacking in its current form. We believe the results will be useful in stressing the importance of the sociocultural context in the recovery of depressive disorders in young adults. We thank the reviewer for taking the time to review our manuscript. -- Reviewer #2: PONE-D-20-07514 A reduced state of being: illness perceptions in young adults diagnosed with depressive disorders Thank you for asking me to secondly review this manuscript. Most of the comments has been well responded, but the following issues still need to be considered to make their effort valuable in cultural diversity and future implication. 1. I’m curious could it be possible that the illness perceptions and experience of your participants have not limited to the CSM framework? The author replied that their interview guide follows the CSM theory, that will easily produce an accordant result with the CSM as their prior framework. How could the researcher prevent yourselves to be mainly influenced by the prior understanding on the existing knowledge on the CSM?\\ Reply: The reviewer is accurate in stating that we are influenced by the literature reviews and CSM framework. While we recognized we are unable to distance ourselves entirely from being influenced by the theory, we had exercised a level of reflexivity that we believed were sufficient. For instance, the first author had written memos detailing her immediate thoughts during the entire process which were discussed alongside the development of the codebook among team members. Additionally, some members were not involved in the initial conceptualization of the study and hence were not informed of the literature reviews or framework. Thus, they had approached the interviews and analyses as ‘blinded’ co-investigators. Finally, interviewers conducted debriefings with their note-takers (if any) about the initial feelings and findings that had surfaced during the interview. 2. The stigma-related issues in non-western society have been mentioned in Discussion; but it has not been reflected from any of patients’ quotations? Reply: While the cultural dimension plays an important role in illness perceptions of mental illness, the themes were too extensive to be reported in this manuscript. Cultural expectations that were directly related to the individual and illness perceptions, such as high societal expectations of success, were reported in this manuscript, whereas themes (and quotes/codes) stemming from the family/society that was more related to stigma than illness perception, will be reported in a separate manuscript. 3. Please clarify some unclear wordings in Discussion, such as: …that was heavily instilled “from young” at home. …the need to further understand depression in relation to goal failure and coping cannot be better emphasized by the temporal overlap. Reply: These portions have been edited to improve readability and we hope it reads better in the next draft. We thank the reviewer for highlighting these areas. 4. I appreciate the revision has added more quotations to reveal the cultural significance, for example: “High societal expectations of success”, and “Unable to pursue personal goals that were incongruent with familial and societal expectations”. Reply: Thank you for the suggestion, we had included more quotes for these themes and subthemes. However, would it possibly relate to the families and the society’s insufficient mental health literacy about depression? It’s suggested to refer existing evidence on the family illness perception and stigma as follows. Please add some related implication as well. Huang CH, Li SM, & Shu BC. Exploring the relationship between illness perceptions and negative emotions in relatives of people with schizophrenia within the context of an affiliate stigma model. J. Nurs. Res 24(3), 217- 223 (2016). Lee, S. K., Lin, E. C. L., Chang, Y. F., Shao, W. C., & Lu, R. B. (2017). Psychometric evaluation of family illness perceptions of patients with schizophrenia. Neuropsychiatry, 7(7), 739-747. Reply: While we agree there is overlap between stigma and illness perception, we had decided to report the theme of stigma in a separate article since it is too extensive to be reported in a single manuscript. Most subthemes of stigma that we had found do not overlap with illness perceptions. For instance, a quote from participant C02 who is 20/Female/Chinese, “they (the family) believe in like those zodiac kind like maybe it’s your bad year. I don’t know. I really... I’m not like those, I’m not superstitious or like believe...I don’t believe in those Chinese, those tradition”, suggests that these religious attitudes that were maintained by the older generations were rejected by the participants. In this manuscript, we had reported only the specific cultural expectations that individuals with depression had articulated to have a direct contribution and relevance to the perception of their illness. Both Huang et al. and Lee et al. examined stigma in relatives of patients with schizophrenia and found that stigma influenced their illness perception toward mental illness. These articles are important as they show how familial attitudes can implicate illness recovery. However, these articles report cross-sectional stigma from the perspective of family and thus may have few direct relevance. Next, mental health literacy and stigma in Taiwan and in Singapore are relatively similar (i.e.: Tonsing, K. N. (2018). A review of mental health literacy in Singapore. Social work in health care,57(1), 27-47.) and therefore we have noted these articles during the drafting of our other manuscript. We thank the reviewer for suggesting these articles as it is relevant to stigma, which we, as an organisation are also highly interested. Thank you. Warm regards, Wen Lin AttachmentSubmitted filename: Response to Reviewers.docx Decision Letter 23 May 2021 PONE-D-20-07514R2 A reduced state of being: illness perceptions in young adults diagnosed with depressive disorders PLOS ONE Dear Dr. Wen Lin Teh, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. As you will see, the reviewers give quite contradictory comments and recommendations. Unfortunately, we had to invite new reviewers for the revised version of your manuscript, this might explain some views different from thjose of the previous reviewers. I tend to follow reviewer 4 and not reviewer 3. However, I would like to ask you to implement as much of comments and suggestions of both reviewers. Please submit your revised manuscript by June 14, 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #3: Yes Reviewer #4: Yes ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #3: Thank you very much for the invitiation to review this interesting manuscript. I have noticed that both the previous review-ers as well as the authors have done a great job in improving the draft. However, I have tried to review the current version as an independent reviewer, and thus focussed my review on the manuscript rather than the previous comments. The qualitative paper describes illness perceptions of Chinese, Malay and Indian young adults living in Singapure with depres-sive disorder. Using face-to-face semir-structured interviews, the authors concluded that participants experienced depres-sion as a reduced state of being. Further, five themes were extracted from thematic analysis. Both topic and study popula-tion seem of interest for the field, yet while I am not an expert in qualitative research and I did not review the first draft of the manuscript, I have some substantial issues with its current version - especially regarding its theoretical foundation and its overall scope. Introduction 1.) In the introduction, the CSM is explained quite well. But the illness representations of mental illness are oversimpli-fied, and studies on bipolar disorder, schizophrenia and later anorexia nervosa combined to construct a narrative stating that “the boundary between mental illness and the self is far less clear [than in case of physical illnesses] and often intersects”. This argumentation completely neglects modern biopsychosocial approaches in medicine, foster-ing dualistic thinking. Second, egosyntonic and egodystonic concepts of different mental illnesses – including de-pression – have been discussed in clinical psychology for years. 2.) The overview of the existing qualitative literature on the topic also seems somewhat random. There are numerous qualitative studies on depression, for example, while the manuscript suggests that “the majority of qualitative work has been conducted amongst severe but less common forms of mental illness such as psychosis or schizophrenia”. This might be true with regard to illness representations, it is however important to be more precise with the re-search question you want to investigate in the manuscript, and what previous research you built your argumenta-tion upon. 3.) When I was reading the sentence “To the best of our knowledge, there has been no qualitative inquiry into illness perceptions of depression that is specific to a non-western psychiatric population residing in Singapore”, I felt like this is the main novelty the manuscript provides. However, reading the title as well as the abstract, I got a com-pletely different first impression of the manuscript’s aims and hypotheses. I think you should really focus on the main research question, rather than generalize qualitative results from a very specific population. For example, I found the description of the multi-ethnic Singapore population really interesting and as an important context factor for the interviews. 4.) I do not really understand from the introduction why you focused on young adults, apart from them being the “most pervasive” age group. I think a group of young people living in Singapor suffering from depression is a very in-teresting, yet also very specific group of patients. I think your work would benefit a lot from focusing on the particu-lar cultural and social insights you may get from this group, rather than trying to generalize the results on depres-sion (or even mental illness) as an entity. 5.) The first reseach question if far too general, and there are numerous (clinical) works on the illness perceptions in (young) persons with depression. As you are not able to answer it with your data, I would at least add “in Singapore” to it, and then elaborate on specific cultural influences in the second research question. 6.) I found the last paragraph in the introduction (your hypotheses?) to be very confusing, as you only give general statements rather than linking them to either your research questions or your data. Methods 7.) Please state what “IMH” stand for. 8.) I am rather confued by the interviews taking place “at a convient place and time”, but then again in the research in-terview room in IMH “to minimize the possibility that participants may describe their illness beliefs in medical terms”. Also, you matched interviewers and patients by ethnicity, without providing any rational why. Further, in-clusion criteria included ability to read and speak English, yet interviews were only “primarily” conducted in English. While there might be many good and interesting reasons to conduct the qualitative interviews the way you did, from a scientific point of view it all sounds very arbitrary. 9.) I think you should provide some information on the interviewers as well (medical doctors, researchers, psycholo-gists?). 10.) Were there any other (methodological) reasons for using thematic analysis by Clarke and Braun rather than the au-thors being familiar with it? Results 11.) I think this section would highly benefit from a figure or an additional numbering, though this is mainly a visual re-mark. 12.) At no point you mentioned the fact that only two of your participants were married. Did this emerge as a topic throughout the interviews? If not, this should be addressed oin the discussion? Discussion 13.) In accordance to 12, you should elaborate further on the specifics of your study population. 14.) I found it interesting to read that depression is “a chronic condition with no means of full recovery”; was this a gen-eral statement or a point of view maintained by all interviewees? 15.) I enjoyed the explanations on the peculiarities of Singaporian culture. As you have a very special study population, I would be careful regarding over-generalizing your findings, though – especially regarding clinical implications and therapy. Accordingly, I would elaborate further on the weaknesses and limitations of the study . Reviewer #4: PONE-D-20-07514R2. A reduced state of being: illness perceptions in young adults diagnosed with depressive disorders This is a very interesting paper handling illness perceptions in young adults in a relatively understudied populations, which makes that the paper contributes to the literature. The paper has been reviewed before and the reviewers provide valuable suggestions which have been answered appropriately by the authors. As a newly, more recent added reviewer I will not go into the points raised before. I really appreciated the wide range of quotes of the participants given in the result section to support the categories reported on. Minor points: The paper’s impact on cultural significance is not reflected in the title of the manuscript. I suggest to revise the title to make the paper easier findable for potential interested readers. Abstract: …surviving with depressive disorders… sounds unfamiliar to me. Do you mean ..remitted .. here? Ending the discussion with a paragraph on the limitations of the study is not elegant and makes it more difficult for the reader to find the take home message of the paper. Please end the discussion with a concluding paragraph reflecting on the research questions given in the introduction of the manuscript (so without including speculations that cannot be derived from the current results). ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. 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Author response to Decision Letter 216 May 2021 Reviewer #3: Thank you very much for the invitiation to review this interesting manuscript. I have noticed that both the previous review-ers as well as the authors have done a great job in improving the draft. However, I have tried to review the current version as an independent reviewer, and thus focussed my review on the manuscript rather than the previous comments. The qualitative paper describes illness perceptions of Chinese, Malay and Indian young adults living in Singapure with depres-sive disorder. Using face-to-face semir-structured interviews, the authors concluded that participants experienced depres-sion as a reduced state of being. Further, five themes were extracted from thematic analysis. Both topic and study popula-tion seem of interest for the field, yet while I am not an expert in qualitative research and I did not review the first draft of the manuscript, I have some substantial issues with its current version - especially regarding its theoretical foundation and its overall scope. Introduction 1.) In the introduction, the CSM is explained quite well. But the illness representations of mental illness are oversimpli-fied, and studies on bipolar disorder, schizophrenia and later anorexia nervosa combined to construct a narrative stating that “the boundary between mental illness and the self is far less clear [than in case of physical illnesses] and often intersects”. This argumentation completely neglects modern biopsychosocial approaches in medicine, foster-ing dualistic thinking. Second, egosyntonic and egodystonic concepts of different mental illnesses – including de-pression – have been discussed in clinical psychology for years. Answer: Thank you for the comments. The biopsychosocial model explains complex individual-environment interactions in relation to illness. Research generally supports the biopsychosocial model as a dominant framework of today and its use have been widespread. Narrative or lay-person models are similar to the biopsychosocial model in that it informs the biopsychosocial aspects of illness. While the biopsychosocial model is commonly used to explain the causality of illness using a three pronged approach, the CSM is used to explain how illness is perceived by the patients themselves. In the narratives, young adults generally endorsed the biopsychosocial model of depression, however, they placed greater emphasis and salience on sociocultural elements. From a social constructivist perspective, sociocultural elements of depression may inform egosyntonic and egodystonic concepts that are relevant to a multi-cultural non-western setting, which can be highly applicable locally since existing models are predominantly western-based. Qualitative approaches thus allow for the voice of culture to be heard. We respectfully disagree with the reviewer indicating that the CSM neglects the biopsychosocial model completely. Instead, both models do overlap, and we believe that the current focus on narratives can inform, substantially, in areas that the biopsychosocial model overlooks, such as culture. 2.) The overview of the existing qualitative literature on the topic also seems somewhat random. There are numerous qualitative studies on depression, for example, while the manuscript suggests that “the majority of qualitative work has been conducted amongst severe but less common forms of mental illness such as psychosis or schizophrenia”. This might be true with regard to illness representations, it is however important to be more precise with the re-search question you want to investigate in the manuscript, and what previous research you built your argumenta-tion upon. Answer: While it may be true that there are numerous qualitative studies that had explored depression in its broadest form, qualitative inquiry into illness narratives of depression in young adults in South-east Asia are few and far between. Most of existing research on illness perception (cited) have been documented in western communities, and the extent to which it is relatable to a multi-ethnic non-western setting may be questioned. While we did expect to find illness narratives to be highly associated with the self and self-concepts as reported by past research, our research questions (and of past research) remained broad rather than specific to capture cultural nuances. Prompts were made to improve the specificity of our interview schedules but they may depend very much on the direction and content of narratives. 3.) When I was reading the sentence “To the best of our knowledge, there has been no qualitative inquiry into illness perceptions of depression that is specific to a non-western psychiatric population residing in Singapore”, I felt like this is the main novelty the manuscript provides. However, reading the title as well as the abstract, I got a com-pletely different first impression of the manuscript’s aims and hypotheses. I think you should really focus on the main research question, rather than generalize qualitative results from a very specific population. For example, I found the description of the multi-ethnic Singapore population really interesting and as an important context factor for the interviews. Answer: We agree with the reviewer that the existing title does not encapsulate the intention and results of our study. We have made further changes to the title to capture our work better. 4.) I do not really understand from the introduction why you focused on young adults, apart from them being the “most pervasive” age group. I think a group of young people living in Singapor suffering from depression is a very in-teresting, yet also very specific group of patients. I think your work would benefit a lot from focusing on the particu-lar cultural and social insights you may get from this group, rather than trying to generalize the results on depres-sion (or even mental illness) as an entity. Answer: Young adulthood is arguably the period where an individual is most productive in life and from an economic standpoint, mental illness can pose a significant threat to productivity and disease burden. This is crucial for Singapore as human capital is considered an important asset. Thus, we have focused on young adults due to this overlap. We have since elaborated our study’s rationale in the next draft. We have added 3 new references to support the claims regarding the importance of culture in treatment relevance for young adulthood, citation [31]: McGorry PD, Goldstone SD, Parker AG, Rickwood DJ, Hickie IB. Cultures for mental health care of young people: an Australian blueprint for reform. The Lancet Psychiatry. 2014;1(7):559-68; Human capital in Singapore, citation [32] Cheng YE. Cultural Politics of Education and Human Capital Formation: Learning to Labor in Singapore. In: Abebe T, Waters J, Skelton T, editors. Laboring and Learning. Singapore: Springer Singapore; 2017. p. 265-84; and Treatment gaps in Singapore pertaining to mental illness: citation [34] Subramaniam, M., Abdin, E., Vaingankar, J. A., Shafie, S., Chua, H. C., Tan, W. M., ... & Chong, S. A. (2019). Minding the treatment gap: results of the Singapore Mental Health Study. Social psychiatry and psychiatric epidemiology, 1-10. 5.) The first reseach question if far too general, and there are numerous (clinical) works on the illness perceptions in (young) persons with depression. As you are not able to answer it with your data, I would at least add “in Singapore” to it, and then elaborate on specific cultural influences in the second research question. Answer: We have included the terms “Singapore”, and “locally” to be more specific, we thank the reviewer for the suggestions. 6.) I found the last paragraph in the introduction (your hypotheses?) to be very confusing, as you only give general statements rather than linking them to either your research questions or your data. Answer: Thank you for spotting this, while we do expect to find similar themes that were reported in past literature, we refrained from the terms hypothesis testing as the nature of the study is exploratory. Methods 7.) Please state what “IMH” stand for. Answer: Thank you for spotting this. The IMH stands for the Institute of Mental Health, the only public state psychiatric hospital in Singapore. 8.) I am rather confued by the interviews taking place “at a convient place and time”, but then again in the research in-terview room in IMH “to minimize the possibility that participants may describe their illness beliefs in medical terms”. Also, you matched interviewers and patients by ethnicity, without providing any rational why. Further, in-clusion criteria included ability to read and speak English, yet interviews were only “primarily” conducted in English. While there might be many good and interesting reasons to conduct the qualitative interviews the way you did, from a scientific point of view it all sounds very arbitrary. Answer: Thank you for noting the contradictions. By default, researchers conducted the interviews in the research rooms that were situated away from the clinic. However, if a participant is unwilling, we would interview the participant at a time and place that is convenient for the him/her. The interviews were conducted in English, but participants, as with all young adults in Singapore, are bilingual, therefore, code-switching to Mandarin, Malay, Tamil, or other languages may happen during the interview. This brings us to our final point on cultural sensitivity. Interviewees were matched with interviewers as much as possible to minimize potential barriers from the lack of cultural sensitivity that may present itself during the interview. We have made changes to the method section to clear this contradiction and we hope it reads better in the next draft. 9.) I think you should provide some information on the interviewers as well (medical doctors, researchers, psycholo-gists?). Answer: The authors (WLT, ES, LC, RK, FD, SS) are all quantitative researchers formal training (degrees in psychology/sociology at least), and we have had since received professional training and are experienced in the use of thematic analysis. Thank you for this suggestion. We have state this in the next draft. 10.) Were there any other (methodological) reasons for using thematic analysis by Clarke and Braun rather than the au-thors being familiar with it? Answer: Yes, we chose this method of analysis because of the advantages it has for researchers working in healthcare. Thematic analysis has several advantages that is favourable for us in overcoming methodological constraints, such as a lack of time, resources, and expertise that are required for many other qualitative approaches. We have included these reasons in the next draft. Results 11.) I think this section would highly benefit from a figure or an additional numbering, though this is mainly a visual re-mark. Answer: We have included additional numberings in this section and we hope it helps to read better in the next draft. 12.) At no point you mentioned the fact that only two of your participants were married. Did this emerge as a topic throughout the interviews? If not, this should be addressed oin the discussion? Answer: Thank you for this comment. In Singapore, the median age at the time of first marriage is around 30 years old for men and 29 years old for women. As the average age of our participants is approximately 26 years old, it was expected that being married would not be a common attribute. Further, we did not find emergent or significant themes related specifically to being married in this study as only a few of whom were married. As only the prominent themes were discussed, we had not reported them. Discussion 13.) In accordance to 12, you should elaborate further on the specifics of your study population. Answer: The specifics of our study population are elaborated in the “Participants” subsection under “Methods”. 14.) I found it interesting to read that depression is “a chronic condition with no means of full recovery”; was this a gen-eral statement or a point of view maintained by all interviewees? It was both. It was a general statement and point of view maintained by the majority of our interviewees regardless of ethnicity. They had initially hoped depression could be resolved in an finite period of time, but they had soon felt it was not the case. 15.) I enjoyed the explanations on the peculiarities of Singaporian culture. As you have a very special study population, I would be careful regarding over-generalizing your findings, though – especially regarding clinical implications and therapy. Accordingly, I would elaborate further on the weaknesses and limitations of the study . Answer: Generalization is not the aim of qualitative research. As reviewer #1 had pointed out, “the aim of qualitative research is not generalization but on the contrary, considering variablity, contextualization, narratives, singularity, experience - therefore it is not a limitation from my view”, which we had agreed with. Thank you for taking the time to review our manuscript. -- Reviewer #4: PONE-D-20-07514R2. A reduced state of being: illness perceptions in young adults diagnosed with depressive disorders This is a very interesting paper handling illness perceptions in young adults in a relatively understudied populations, which makes that the paper contributes to the literature. The paper has been reviewed before and the reviewers provide valuable suggestions which have been answered appropriately by the authors. As a newly, more recent added reviewer I will not go into the points raised before. I really appreciated the wide range of quotes of the participants given in the result section to support the categories reported on. Minor points: The paper’s impact on cultural significance is not reflected in the title of the manuscript. I suggest to revise the title to make the paper easier findable for potential interested readers. Answer: Thank you for this suggestion. We have made slight changes to better encapsulate the significance of culture in this manuscript. Abstract: …surviving with depressive disorders… sounds unfamiliar to me. Do you mean ..remitted .. here? Answer: Yes, we do mean remitted and have changed that term. Ending the discussion with a paragraph on the limitations of the study is not elegant and makes it more difficult for the reader to find the take home message of the paper. Please end the discussion with a concluding paragraph reflecting on the research questions given in the introduction of the manuscript (so without including speculations that cannot be derived from the current results). Answer: We have added a paragraph to properly conclude and summarise the study’s aims and findings. Thank you for taking the time to review our manuscript. -- Thank you. Sincerely, Wen Lin AttachmentSubmitted filename: Letter to Reviewers 3.docx Decision Letter 326 May 2021 A reduced state of being: the role of culture in illness perceptions of young adults diagnosed with depressive disorders in Singapore PONE-D-20-07514R3 Dear Dr. Teh, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. 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Kind regards, Stephan Doering, M.D. Academic Editor PLOS ONE Acceptance letter1 Jun 2021 PONE-D-20-07514R3 A reduced state of being: The role of culture in illness perceptions of young adults diagnosed with depressive disorders in Singapore Dear Dr. Teh: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact gro.solp@sserpeno. If we can help with anything else, please email us at gro.solp@enosolp. Thank you for submitting your work to PLOS ONE and supporting open access. 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