Introduction

Mental health problems among adolescents and young adults (AYA) have surged significantly during recent decades [1–3]. Globally, it has been estimated that one out of every seven AYA are vulnerable to developing mental health problems [4]. The escalated trends in mental health problem prevalence presents an immediate public health challenge deserving urgent concern [1]. That is the magnitude of this problem, which impacts many AYA.

This challenge is further compounded by the devastating implications. Mental health problems are becoming more widespread, and more people require to visit counseling and psychiatric centers. Additionally, the dependence upon psychotropic agents to treat this group of AYA presents another complex dimension of care. [5, 6]. It has also been reported that the presence of mental health problems among AYA has the potential to affect their education and ability to acquire important life skills which, in turn, could have an effect on their quality of life and meaningful existence [7].

One way to shed light on the challenges faced by AYA with mental health problems is to employ a lived experience paradigm [8] in examining their subjective experience. The lived experience paradigm is part of a phenomenological or ‘emic’ approach and, according to Neubauer, Witkop [8], the paradigm aims to understand “what was experienced and how it was experienced” (p. 91). While a plethora of studies have employed the lived experience paradigm in developed countries such as the United States, Canada, the United Kingdom and other countries in Western Europe as well as some countries on the Pacific Rim, there have been very few investigations using the paradigm in emerging economies [9]. Demographic trends in developing countries suggest the presence of a ‘youth bulge’ in the pyramidal population structure, indicating the preponderance of young people [10]. More initiatives using emic approaches are therefore needed to understand the experience of AYA suffering from mental health problems in developing countries so that mechanisms to safeguard their well-being could be developed.

Studies carried out in Western countries and using phenomenological approaches such as lived experience have suggested that AYA with mental health problems go through unpleasant experiences in their search for treatment [11, 12], with negative repercussions on their quest for a meaningful existence [13]. In a study by Woodgate [14], adolescents with mental health problems described themselves as “walking zombies”, meaning that they saw themselves devoid of free will and the ability to control their lives. Additionally, previous research has linked the presence of mental health problems among AYA with poor academic performance [3, 15] as well as inadequate self-care, poor personal development, and poor socialization skills [16, 17]. Researchers have documented that AYA with mental health problems have an increased chance of causing self-harm [18] as well as developing sexual and reproductive health problems [19]. Such detrimental and maladaptive behaviour has been reported to persist even when there is remission of overt mental health problems [14, 20]. In most societies around the world, there are varying degrees of exclusion and marginalization of people with mental health problems and indeed AYA experience stigma and discrimination. This is consistent with reports that mental health problems among AYA are intransigent and debilitating and often create dependency [4].

The Arabian Gulf countries are “home to one of the youngest populations in the world” [21]. As one out of seven people globally is likely to succumb to mental health problems [4], it is likely that such a trend also exists in the Gulf countries, although as always, mental health problems often cause different degrees of distress and symptomatology [22]. While the standard of living in this region has significantly improved in recent years due to the exploitation of hydrocarbon and the development of transhipment services [23], the welfare of people with mental health problems is often not given enough attention, likely due to a lack of mental health literacy in the region. A systematic review on mental health literacy conducted by Elyamani, Naja [24] discovered that mental health awareness remains suboptimal in the Gulf countries among healthcare professionals and the public. Parallel to the low level of mental health literacy, studies have suggested the presence of pervasive stigma toward people with mental health problems [25, 26]. Similarly, despite the development of the biomedical model, there is wide under-utilization of existing psychiatric services [27]. Mirza, Al-Huseini [28] have indicated that due to the long duration of untreated mental health problems among AYA in Oman, many of those who eventually seek consultation from psychiatric services are likely to be those with more advanced and irreversible pathology, making them impervious to the treatment offered.

While a reasonable number of etic (outsider-oriented) studies have illuminated the prevalence of mental health problems, there remains a significant gap in understanding the emic (insider-oriented) approach, this study is distinct in its focus on Omani adolescents and young adults. That is, while prior work has been invaluable, this research acknowledges a need for a personalized approach within Oman where cultural and social factors may influence experiences of AYA with mental health problem. This study explores the lived experience of Omani AYA with mental health problems. The objective is to gain a deeper understanding of the key characteristics of their lives, with the overarching aim of identifying critical factors that may contribute to their mental health issues. Through this research, we provided an insight into the desperate requirement for more specialized mental health services for these AYA in this cultural setting.

Methods

Interpretive phenomenological analysis (IPA) methodology was used in this study to describe the experiences of AYA with mental health problems. This approach was used because, when little is known about the phenomenon being examined, the methodology allows for complex descriptions of lived experiences to be reported and documented [29, 30]. In-depth interviews using open-ended questions were used to allow participants to express their views and experiences in their own words. Interviews were then transcribed and converted into a format suitable for analysis. Following interpretive methodology, thematic analysis was applied to identify recurring themes and meanings within the data. To understand and interpret the meaning the AYA ascribed to their experience, a systematic process was used for coding and categorizing data. This process is described in Section 2.4.

2.3 Data collection

The data collection took place between October 30, 2021, and November 10, 2022. The research assistants requested the contact details of the parents of AYA with mental health problems from the nurse managers in the outpatient department. Parents were then contacted by telephone during which the purpose and nature of the research were explained to them, and they were asked for their consent to interview their children. After obtaining written consent from the AYA and their parents, the researchers organized face-to-face interview sessions with the AYA in the presence of their parents at a mutually agreed time and place. At the beginning of each interview, participants were presented with an information sheet to read which included information about the purpose and procedure of the study. They were given the opportunity to ask any questions related to the study. After agreeing to participate, they were required to sign a consent form. Participants were informed that their responses would be kept strictly confidential and that they were allowed to withdraw from the study at any point and without giving reason. Care was taken to ensure participants were comfortable prior to and during the interview. Breaks during the interview were encouraged, if needed. Additionally, participants were informed that if they experienced any distress or discomfort during the interview, the researcher would promptly stop the interview. Interviews were conducted by an experienced research assistant with graduate-level expertise in clinical psychology. The researcher was trained to build rapport with the interviewees by establishing trust, a positive relationship and open communication. To ensure data integrity, each independent and in-depth semi-structured interview was recorded digitally, with each interview lasting on average 60 minutes. Examples of the interview questions are presented in Table 1.

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Table 1. Sample questions for the interview.

https://doi.org/10.1371/journal.pone.0294856.t001

Results

The data was collected between 17^th of October 2021 to 19^th of July 2022. Fifteen AYA with a mean age of 17.2 years participated in the study (9 female, 6 male). Three had been diagnosed with Major Depressive Disorders (MDD) and bipolar disorder; seven had MDD and borderline personality disorder; another three had MDD and obsessive-compulsive disorder; and the last two suffered from MDD only. All the participants had lived with their mental illness for more than nine months since diagnosis. Three major themes emerged, corresponding to three phases related to the disease namely: the pre-diagnosis phase, the journey after diagnosis, and future life with mental illness. These themes are “living in darkness”, “perilous journey” and “uncertain future”.

Discussion

Various studies in Oman have explored the prevalence and associated factors among children and AYA with mental illness [10, 32]. To date, no qualitative studies have explored the lived experiences of Omani AYA with mental health problems. The onset of mental health problems is associated with the period of living in darkness, characterized by obscurity about the cause and diagnosis of their mental health problems. This darkness period resulted in significant delays in the diagnoses. In terms of the cause, some participants associated the onset of mental health problems with supernatural causes such as the evil eye, witchcraft, or demonic possession. These participants seem to suggest that the onset of their symptoms coincided with a third party’s malevolent involvement. This supposed cause of distress, which differs from the medical model, has been previously documented in various populations [33, 34] including Arab-Islamic society [35–37]. This seems to indicate that belief in the supernatural cause of mental health problems persists across civilizations, income levels, and racial groups [38, 39]. On one hand, to conform to the biomedical model, it may be necessary to enhance public awareness about mental health problems through mass media, social media, and public lectures. On the other hand, traditional healing practices could be further scrutinized and integrated into existing healthcare practice. Such an integrative approach has been reported to have heuristic value in non-Western populations [40].

The second reason for living in darkness relates to the delayed diagnosis and treatment experienced by the AYA in part due to diagnostic overshadowing, or being unsure of the diagnosis. This delay may be partly explained by the fear and reluctance of families to seek mental health care, as reported among Arab populations [41]. It may also be, as in a US-based study of Asian Americans by Okazaki [42], that some families delayed seeking healthcare services because of the shame they felt and the stigma attached to mental health problems. In addition, our findings revealed that many physicians initially associated mental health problems with physical illness, which also lead to delays in treatment.

The present study and related literature appear to indicate that delayed diagnosis of mental health problems is a pervasive problem worldwide. For instance, a cross-sectional survey conducted in Vietnam concluded that people with severe mental health problems living in poor and middle-income countries often experience extended diagnosis delays, hindering their access to medical treatment [43]. Similarly, a UK study found that diagnostic overshadowing and the resulting delays were a significant issue often characterized by poor communication among key players [44]. All of these delays, unfortunately, lead to longer waiting times for diagnosis and treatment of the main pathology, with possibly serious consequences [45, 46]. These unhelpful delays and the lack of clarity on the actual cause of mental health problems among patients and families means that AYA continue to live in the dark for a prolonged period before they receive a proper diagnosis and commence treatment. This calls for evidence-based strategies to reduce the waiting period.

The perilous journey theme reveals three main challenges that face mentally ill AYA in the present cohort. The first is the short consultation time with their primary physicians and mental health workers. In Oman, healthcare services are provided free of charge to Omani citizens, creating significant strain on the limited mental health care resources available. This has been previously reported to adversely affect the doctor-patient relationship, as well as cause poor compliance which, in turn, can trigger poor health outcomes [47]. In a systematic review, Irving, Neves [48] scrutinized the literature from 1946 to 2016 on consultation time in primary healthcare settings around the world. The review identified 179 articles that fulfilled the inclusion criteria. It suggests that geography has a direct bearing on consultation time, with a clear-cut north-south divide; countries in the global south were more likely to have shorter consultations than those predominately in the global north. Countries in the global south are likely to fulfil the criteria of being lower- and middle-income countries [49], which often have a shortage of healthcare workers amid the rising tide of both communicable and non-communicable diseases. The role of geography might contribute to the observed short consultations in the present study, in a region where mental health services are understaffed and maldistributed [50]. In addition to the north-south divide, in any given society there is evidence to suggest that socio-economic status has a direct bearing on the consultation time. In France, Videau, Saliba-Serre [51] explored the consultation time of patients seeking help forMajor Depressive Disorder (MDD) from general practitioners. This study strongly suggested that consultation duration was invariably related to the socio-economic status; that is, the poor were given the shortest consultation time. In a close-knit society like Oman, one’s identity often owes its origin to the tribe. However, more recently, income is increasingly becoming a defining feature of social status [52]. Whether traditionally defined or modern finance-based socio-economic status may play a role in determining consultation time. Such short and rushed consultations added to the perilous nature of the journey as the patients felt not “being properly attended to” and described the visits as “non-productive”.

In addition, the psychotherapeutic sessions were not perceived by the interviewees to be constructive, for two possible reasons. First, many of the psychotherapy modalities dispensed by Omani psychologists rely on the Anglo-American model where there is emphasis on the individual as a separate entity. In Western psychology, when the ‘ideal self’ is incompatible with the ‘real self’, the individual is likely to experience guilt. Such societies have been labelled as guilt-based [53]. Prolonged intrapsychic guilt has the potential to trigger intrapsychic conflict which may culminate in full-blown mental health problems [54]. In contrast to guilt-based societies, interdependent Omani societies use shame as an instrument for socialization. Thus, individuals moulded in a collective mindset may find Western psychotherapy useless, as explained by one of the respondents. The point of divergence is that Western psychotherapy tries to unlock intrapsychic conflict [53], whereas in a shame-based society sources of stress are likely to be attributed to disequilibrium in social relationships. Thus, according to Al-Sinawi, Al-Adawi [55], when individuals experience stress and distress in Oman, they are likely to attribute their difficulty to an external agent such as “hassad (an evil spirit of contemptuous envy) or being targeted by sihr (sorcery)” (p. 697). Such attribution would require the therapist to disentangle social relationships rather than intrapsychic guilt. Therefore, it was not surprising that the respondent found psychotherapy “useless”. Secondly, the quality psychological interventions provided by clinicians has been criticized. According to Al-Darmaki and Yaaqeib [56], “The practice of providing psychological services such as counseling and psychotherapy remains loosely regulated by the authorities. The lack of enforced rules of practice have enabled ‘bogus’ psychologists and mental health workers who exploit legal loopholes to operate…” [56]. Related to this, it is a common observation that humanities graduates are employed to work as clinical psychologists [57]. To improve psychological outcomes, a concerted effort is needed to work on developing culture-sensitive intervention and, related to this, better quality assurance procedures for interventions provided by practitioners.

Another significant complication during the adolescents’ journey is the side effects of psychotropic medication. The participants reported untoward effects of the medication complicating their treatment. This drug-related distress seems to be a common problem across patient populations. For instance, Lucca, Varghese [58] revealed that adverse medication reactions range from 5.9% to 45% in the Indian psychiatry population. Similar drug-induced side effects were reported among the American population by Covell, Weissman [59]. Like our study, the most common distressing side effects were cognitive impairment, embarrassment from weight gain, dry mouth and sedation, and the feeling of being “weird” like a “zombie” [14, 60]. These findings point towards the need to improve the quality of physician consultations as well as mechanisms to reduce non-compliance with intervention due to side effects. One possible avenue is to explore adolescent-specific health education on the side effects of psychotropic medication [61]. In the Arabian Gulf region, pharmacotherapy appears to be the mainstay of intervention for people with mental distress [62, 63]. A concerted effort is needed to explore whether there is likely to be culture-specific psychosocial intervention that could be used as an adjunct to pharmacotherapy [64].

The third theme, uncertain future, relates to three fears: the possibility of relapse, the possibility of serious effects of the medication, and the possibility that patients may never recover well enough to return to normal functioning. These fears are deeply embedded in the psychological well-being of adolescents, affecting their adherence to treatment and, ultimately, their recovery. The psychological impact of these fears underlines the necessity of interventions that increase resilience and coping strategies among affected adolescents. The first uncertainty, possibility of relapse, is manifest in adolescents’ fear of again losing control of their thoughts. The literature describes the fear of relapse affecting not only patients, but extending to family members. A Canadian study showed family members of young people receiving services for a first-episode psychosis extremely worried about relapse, typically accompanied by considerable levels of dread and anxiety [65]. An earlier study reported that this is a serious condition that warrants attention since fear of recurrence has been linked to increased risk of relapse and poorer emotional recovery [66]. Furthermore, the study found that the greater the fear of relapse, the shorter was the duration before the actual relapse in people with mental health problems.

The second reason for the adolescent’s uncertainty relates to the side effects of medication. Such fears mean that they might not adhere to the regime, further complicating their recovery. A systematic evaluation of the factors for medication non-adherence in individuals with significant mental health problems found that side effects accounted for 27.8% of the reasons why patients quit taking medication. This is an important finding since interruption of treatment for as little as one day is associated with increased risk of hospitalization in patients with certain conditions such as schizophrenia [60, 67].

The third reason for uncertainty is the fear that the disease may compromise patients’ return to normal routines, such as school attendance. Usually, uncertainty increases when people are unable to plan for their future due to life-changing transformative conditions. The uncertainty the AYA experienced in our study is comparable to the uncertainty that was prevalent during the 2020–21 COVID-19 pandemic which significantly interfered with people’s social, economic and mental wellbeing [68]. As a remedy, such uncertainties call for strategies that increase the resilience and coping ability of affected AYA.

The lived experience of the AYA with mental health problems, pending further scrutiny, would require paradigm changes to meet their unmet needs. To address the concerns on living in darkness, concerted efforts are needed to reduce stigma and improve mental health literacy across all strata of society. Innovative approaches may include adding new content to the extant secondary and tertiary education curricula on mental health problems. In terms of how efforts to make the treatment journey less perilous, healthcare services in Oman should apply best practice in their prescription policy, as well as consider the development of culture-sensitive therapies. Health education is needed to enlighten AYA about the pros and cons of complying with the prescribed medication for mental health problems. As consultation time was deemed inadequate, sufficient interaction should be promoted. Last but not least, to address the concern of an uncertain future, deliberate efforts should be employed to help educate AYA on prognostic indicators of their presenting mental health problems. The lifestyle changes that lead to positive prognostic indicators should be emphasized. In the final analysis, the new mantra should be to employ a biopsychosocial approach to safeguard the wellbeing of AYA.

Conclusions

The present study provides new insights into the experience of Omani AYA with mental health problems. The AYA interviewed faced several challenges, the most significant of which was lack of understanding of their condition at the onset of symptoms, leading to delays in the treatment process. Our findings indicate that there is a need for developing culture-sensitive interventions and improving the quality of psychological services in Oman. Implications of our findings lie in the development of approaches and mechanisms for preventing or mitigating difficulties faced by AYA with mental health problems.