Introduction:

The concept of illness and health is in the core of human societys values. Because
they explain our images and assumptions about death and life. (Digzet 2005
according to Turner). Illness has its own definition from social perspective. Being
healthy or ill is never same for people. Concept of healthiness and illness cannot be
interpreted numerically. Human illness are either physical or mental. Definition of
physical illnesses are far from hardship of mental diseases definition because they
can be recognized through their causes and certain symptoms. But mental diseases
cannot be defined or interpreted easily. In a brief definition as physical illness relate
to anatomical and genetic background, concept of mental diseases inevitably relate
to social background including ethics in which it has been developed (sas 1957, a
,b). Mental diseases generally is used to describe those disorders which are different
from brain illnesses. Depression and anxiety are a part of mental illnesses and
because of its importance and spread, is known as mental colds among
psychologists and psychiatrist. In 1990 depression was 4th common disease while it
is forecasted to become 2nd common diseases in 2020 after heart diseases. (World
health organization). In definition of depression it must be considered that
depression has biological-mental and social nature and occurs with wide range of
symptoms and reasons. In other words, depression is a disorder which affects ideas,
thoughts, emotions, behavior and even physical health.
Major depression syndrome has at least five symptoms including, exhibiting a very
low mood, loss of interest or pleasure, gaining or losing weight, insomnia,
overeating, fatigue, lack of energy, feeling of worthlessness or guilt, decline in
thinking ability and thoughts about death during two weeks shows a change in
former moods and spirits. (Kaplan and sadok 1997, 146)
According to the statics given above about the outbreak of depression and also
difficulty of defining mental disorders, the necessity of studying depression from
different social points of view is evident.
An issue in which we face in the beginning of sociological study of disease is that
the concept of illness like other human concepts has underwent fundamental changes
through time. Sociology points of view which studies illness is usually subset of
medical sociology studying the causes and social factors of illness. There are two
major theoretical classification in sociology which represents two points of views
about societies and how to know them. Theories in which defines societies as social
construction believe that societies are network of social institutions and indicator of
social relations and has a long history. Sociologists who have accepted this point of
view have tried to show that social constructions shape the behavior of individuals
living within it. Sociologists who has studied health and illness form structural
perspective should pay attention to factors like culture, social class structure and
educational system which focuses on health behavior and health. And should
scrutinize the vulnerability of these factors toward illness and health care
organizations. (keyvan ara)
The second part is kind of theories believing that societies are result of individuals
action. These theories focus on interaction with others. According to social action
theories, since societies are result of individuals activity based on their intentions,
sociologists should begin their studies with society and studying of individuals
actions and meanings beyond their actions. (keyvanara). Sociologists who study
health and illness from social action perspective, discover things such as what
individuals definition of health and illness is or what experience of health and
illness do they have or their definition of daily interaction between health specialties.
(keyvanara)
In every society, cultural rules determine who is patient and what sort of behavior
should be expected from him/her and his/her associates. (qanei, karimi, 2006)
Social constructionism is one of the most important theoretical approaches that study
and interpret subjective experiences. Social constructionism can be considered as a
more sociological version and more centralized paradigm of cultural meanings.
(qazi tababai 2006). Social constructionism is a strong perspective which believes
cognition is acquired through interaction and human interpretation. Social
constructionists believe that cognition is not general, fixed or neutral but always is
being changed in reaction to social relations. This issue in regarding to medication
means medical cognition; about body and its pathology- both in physical and mental
diseases- basically cannot understood apart from society and cognition. (gap 2004)
Constructionism approach focuses on our cognition and understanding outside world
and not on the issue that how is outside world independent from our understanding?
This approach less deals with soul of material world. For this reason it can be said
that social constructionism deals with social issues as subjective meanings and
understandings (luzik). So, social constructionism theory indeed is subjective
structures or creatures of individuals mind. Social constructionism is an approach
that focuses on a procedure in which social conditions or situations seem
problematic. In this approach the way of construction of social issues through
interaction between agents and effect of social process on perception and action of
agents is studied. Illness like other human experiences has different social
consequences and according to this approach, it is a social construction. Each human
experiences and percepts his own illness under his own social circumstances in a
unique way and it may be different from perception and interpretation of other agents
about the same illness. Humans experiences and their perception of lived
experiences are in focus of social constructionism. Medical sociology is a branch of
social constructionism approach that is very close to Foucaults theory and analyzes
body as a result of power and knowledge. Other branch of constructionism, which is
based on burger and lakman work titled social structure of reality, is based
on symbolic interaction and its emphasis is on human agency thus has many different
meanings for perception of relationship between patient and physician. In this book
the phenomenology of shutz has been translated into conventional sociology theory
and its link with social psychology has been strengthened.
Philosophical approach of phenomenology is base of both symbolic interaction and
social constructionism approach. This two sociological approaches are from those
theoretic approaches that emphasize on formation process and effective factors on
how meanings was formed and individuals actions. In the present research, due to
subject, construction of illness, and sociological study of patients experience with
depression and anxiety disorders theoretical approaches of social constructionism,
symbolic interaction and phenomenology has been used for achieving research
objectives and answering research questions.
The main question of this research is perception of lived experience of people with
depression and anxiety disorder.
Methodology
Qualitative approach in social researches which is affected by symbolic interaction
theories makes the researcher to study how things seems as an outside reality is
indeed is a social construction. Thus, qualitative approach provides a very different
perception of human and nature of social order and structure. This point of view
considers human as an active agent and generally dominant of outer social structures
and inner-subjective states. In scientific researches with this approach social-
subjective processes is a key concept. The reality which is studied in qualitative
researches is created by many different agents. Focus on perspective of those who
were surveyed and meanings they give to the experiences and events followed by
orientation on the meaning of phenomena, activities and events have affected a
major part of qualitative researches. (fleyk 2011)
According to research subject, which examines the thoughts, images, and emotions
of patients and in general perception and experience of patients about their illness
the best method to achieve and perception of patients subjective world or
phenomenology of illness from patients perspective is grounded theory. The
underlying theory is a theory that is directly mined out of collected and analyzed
data in the research process. In this method, data collection, analysis, and final theory
are closely connected with each other. Analysis in this method means contrast of
data and researchers mind. In qualitative researches interview is one of the ways of
collecting data. In this research in order to discover the hidden aspects of patients
subjective world as well as perception of their lived experience narrative interview
method is selected. Narrative interview as a specific method of collecting data about
personal experiences has been presented by Shutz and in comparison to other forms
of interviews provides richer information about events and experiences. What we
seek in narrative interviews is not a pile of data about individuals life but achieving
to a scientific theory about structured processes of research. In this study, the
researcher aims to understand the life process of mentally ill, depressed and anxious
people through their narrative.
Methods of study:
To do this study, while the researcher referred to a mental hospital to interview with
patients faced lots of problems by the hospital staff. So, for doing the research the
researcher has asked her friends to introduce some cases with severe, mild or
periodic depression and even cases with experience of being hospitalized to
interview with them. After implementation, coding and analysis of first interview,
the researcher did the same thing successively to a point that according to grounded
theory after 15 interviews it seed that there is no new concepts to be discovered. In
this study, the sampling procedure is done on the basis of theoretical sampling
method which is the proposed by Grounded theory for qualitative researches. The
basic principle of theoretical sampling is to select items or groups based on their
content rather than using abstract methodological criteria. The sampling is done
based on the relevance of the case to research. This principle is the characteristic of
strategies related to data collection in qualitative researches.(fleyk 2009) In other
words, mentioned decisions in sampling, target those information in the light of the
knowledge that has already been used and apparently knowledge which is extracted
from them is the most informative on the issue. (2009) According to the above-
mentioned problems for reaching the patients including time-consuming
administrative problems and cheerlessness of patients due to taking medication, the
sampling of this research is conducted through the network of friends and familiarity
with the individuals who have experienced depression. Interactive talks with patients
in the hospitals waiting room in each visit of hospital served as a spotlight on the
information provided by the other interviewees and perception of disease from their
perspective. Research samples were from ages 20 to 40 years old and were university
graduates. Due to interviewees higher education as well as their power of analysis,
they were able to provide comprehensive information on different aspects of their
experience. Also interviewees in comparison to patients in the hospital who had not
higher education and were living in families with low education, the importance of
education in overcoming the illness alongside patients active role in improving their
mental condition were indicated. During the interview all samples were out of severe
depression and based on their remarks because of their ability to withstand
conditions of severe depression they had earned the ability to deal with mild
depression. This ability was expressed as coping with depression by interviewees.
The following table shows the demographic information of the participants in
interview.

Patient gender age Marital status education career

1 Female 35 Married B.A Elementary
Teacher
2 Male 32 Single Fired Student Unemployed
3 Female 35 Single M.A Painter
4 Female 34 Single M.A Unemployed
5 Male 28 Single B.A Translator
6 Male 24 Single Associate degree Lifeguard
7 Female 30 Single B.A Student
8 Female 26 Single B.A Unemployed
9 Male 39 Married B.A Teacher
10 Female 37 Single M.A University
Lecturer
11 Female 22 Single Diploma Unemployed
12 Female 33 Married PhD University
Lecturer
13 Female 34 Divorced M.A Unemployed
14 Male 32 Single Associate degree Shopkeeper
15 Male 29 Single B.S Engineer

Findings
After asking demographic questions, narrative interviews with patients were began.
The initial question was: what is your definition of depression? Or what is depression
in your opinion? These questions provided a deeper and more complete insight into
patients image of depression. In the midst of interview and according to
conversation current following questions were asked:
1. How did you depressed?
2. Were you aware of your depression or someone else told you?
3. How much familys economic situation was effective on your depression?
4. Does psychiatrists and anti-depressants effective in improving depression?
5. Which moods did you experienced while you were depressed?
6. Did you informed your family and friends about your depression?
7. What is others opinion about depressed people?
8. How did you recovered?
9. How was your friends behavior toward you after recovery?

For analyzing the interviews through grounded theory the first step is to analyze the
open coding in which is an analytic process that the sequences of data and
specification of them is measured. Next step is axial coding which makes the process
of connecting categories to subcategories possible. Then after identifying the core
concepts in interviews, refinement and integration of data in the form of theory were
conducted. Although this stage is fluid during the study and is formed by interaction
among subjective images of researcher, his studies and interviews. Researcher
analyzed the interviews based on the book by Anselm Strauss and Juliet Corbin
about qualitative research methods. The main concepts of the interviews have been
discovered during analysis using open coding is given in the following table.
Inability in Considering Feel of guilt Inability in Having Other opinions
communicating with everything and self- controlling different
others absurd and blaming their own desires
considering destiny or and
life lack of wishes in
worthless decision life
making
ability
Feeling of being like a Mortality Others were Being Not Ineptitude and
remote island Think of pitiful toward forced to wanting to irresponsibility
Feeling like falling in death me make get marry toward
a well Repeating Feeling of important Difference important
A state of pervasive the concept ineptitude decisions in attitude issues
silence of so toward against my with Weakness of
State of shock and what? responsibilities will in others due character
surprise Considering Feeling of some to studies Disrespectful
Helpless everything shame due to phases of toward life
Stillness and silence worthless depression life gifts
Dejection Lack of Unreliable
Mortal motivation Hiding
A harmless disease to change depression
Inability in from others
communication
Not having mutual
understanding

This table contains important concepts and their consequences that were obtained in
open coding phase. In axial coding categories, phenomena, connections among
concepts and discovering ways through which different categories are related to each
other is analyzed. So, through this way, conditions, actions/interactions and
outcomes are discovered. What were discovered in interviews and analyses in axial
coding, has been assessed in three categories:
1. Pre-disease stage and background of disease
2. Stage of disease and perception of depression
3. Attempt to acquire healthy peoples identity
According to the interviews what lead patients into depression and made them
depressed in most cases were feeling of difference, inability to communicate with
others and being isolated. As one of the interviewees says:
Case number 5: I got depressed because of my studies. I was studying books which
my fellows studied 10years later or never studied. I never watched TV and I did not
know what my fellows were talking about in the school. Even once I slapped one of
my classmates because he was trying to mimic a famous TV shows actor but I was
not able to understand that. These kind of differences makes you to get used to your
loneliness and isolation. And you are trying to build a wall between yourself and
others. So this loneliness and isolation become your identity. Never trying to break
down that wall that separates you from others. You do not have anything in common
with others and even you are not able to talk about weather with other anymore. This
is how isolation is formed and it can depress you later.
Sometimes being forced to make decisions against your will can result in depression.
One of the interviewees says:
During high school my family and teachers somehow forced me to study field of
science. I love to have an independent character. I want my thoughts and decision to
be based on my own taste and idea not others choice. During high school I didnt
like my courses and my results were poor because others forced me to study science.
I was very upset because they forced me to study a field that I didnt like. I was not
independent and this was a tension for me as a teenager.
Sometimes the spirit of competition for achievement can lead an individual into
depression.
Case number 4 says: I am not a carefree person. I want to make progress but because
of economic problems, failure in winning financial support from family or
disagreement of my family with my ideas resulted in my failure. And I couldnt
become the one who I wanted to be and this depressed me.
In some cases, events such as the death of loved ones is causing depression, but
according to psychologists this state of depression happens for everyone. But in
some cases long-lasting stay in this mood can be caused by feeling guilty and self-
blame for the lost one and obsessive thoughts derived from it. Case number 1 says:
Because I didnt listened to my father on my marriage, I had not seen him for years.
He had cancer and he was in coma. I couldnt talk to him because when he was
conscious and called me I was not there. I regret and blame myself most of the time.
Those days signs of depression appeared in me. The world was worthless for me, I
didnt care about anything, later I somehow accustomed to this circumstance.
In the stage of being or experiencing disease, the central and common issue in
interviews is interviewees description of depression by different words like heart
attack or well indicating that in depression the depressed one is in a mood that
needs help of family or friends. Family or friends can help depressed people by
taking them to psychologist or psychiatrist or saving them from committing suicide.
Depressed person is not aware of his mood in detail and they describe their mood by
general phrases like heart attack, dejection and inactivity. What interviewer
inferred about severe depression and their perception of that mood through their
remarks depression seems something like unawareness from outside and real world
also interviewees were not aware of their mood during illness. Unlike physical
diseases that patient perceives his disease in detail and even attempts to cure it. All
of the interviewees were taken to psychologist or psychiatrist by their family. In
some cases patient did harm to himself in order to awaken the feeling of being alive.
It this case it seems that the world of disease is in harmony with the world of passed
away as shutz says. A world in which due to absence from it we are unable to
perceive it comprehensively. Even patients, after recovery, become stranger to those
moods and are unable to describe the experienced world vividly. According to shutz
what people think they know, is important and what is accepted as knowledge is
present in social life. Social meanings are created in interaction between humans.
Case number5: you have strange feelings, you want to injure your body, and this
pain is not pleasing but somehow you convince yourself that I am alive. It helps your
body to get out of that dejection. I was lying on my bed for many hours even I didnt
get out of my bed almost for a year. But sometimes you use pain as a tool to check
that whether I am alive or not. I dont remember lots of things or how those days
was.
Case number3: passed, but how? I cannot remember exactly those moods. Or even
how time passed. I can just remember a sentence that I used to repeat all those days.
If I do not die now I will survive I cant remember how long those days lasted.
Just can remember a sentence if I do not die now I will not die. There was too much
stress on me that I was afraid to die. I can just remember it was 8 years ago. Even
now I am talking about those days my heart aches but I know I wont be like that
anymore.
Case number 10 answer to the how long did your disease last? says: his answer
was indecisive and full of doubt. I dont know how long it lasted. Those days I
thought it lasted for two years but now I think it took almost four years. I cant
remember exactly. Also in other cases this answers were given with different words
like:
Case number 9 says: it doesnt like catching cold. It looks like apoplexy. Many
hours, days and months passes but you are not even aware that time passes, you are
unaware of yourself and world. In this cases a help team should support you.
In the third stage, and after a relative recovery. Patient tried to assess reaction of
those people around him. According to interviewees remarks in the process of the
disease patients become very vulnerable, fragile and they have unstable self-
confidence about themselves and their position in the society. Being neglected was
the most important issue and core concept in the interviews. Others reactions toward
them resulted in shaping of this image in the patients that they cannot be counted on
as an adult. Patients believe due to their disease and the disturbance in their ability
to do things, they have lost their social credit. Social credit means to count on
somebodys words, expecting to do the asked responsibilities. After recovery
through interaction between others patients find out they are not behaved as a
capable adult just because of their disease.
They said:
Case number 5: my study hour was extended, I was sleeping almost in the morning,
I couldnt attend university classes, my results were poor, and depression disturbs
ones eating and sleeping habits. You cant keep your words, you are always late.
Case number 9: friends usually judge based on your appearance and relations. I
mean, if a friend of yours knows you are depressed and you are not in mood of doing
anything or you cannot even do something, they think they cannot count on you,
they try not to continue their relationship with you and even sometimes ignore you.
Also patients told about their families:
Case number3: if your disease takes a long time they try to behave with you like a
child. For example they do not trust you, or whatever you say they do not consider
as an important or serious saying. They want to misuse you and if you want to show
your objection they remind you that you are a mentally ill person or you are patient
and so on.
These actions takes place in the context of everyday life and interactions as well as,
their circumstances shape the patients vision. Even if the patients do not expose to
the label of depression they feel neglected. Some of the patients were trying to hide
their depression as a defensive mechanism. All patients agreed that their family was
trying to hide their disease. Married people in this regard mentioned that depression
weakens their marital relationship and disturbs it. Case number 1 says: in your
marital relationship you have to listen to your spouse. This turns into misuse. I mean
your spouse misuses you. Sometimes your spouse blames you and sometimes
rebukes you. And when this happens over the time and you feel your spouse is
misusing you, you get upset. Once I realized that I should sort out things, I dont like
to be a weak person. Patients tend to hide their depression in work place more than
they did in their family. Because, experience shows that when their employer was
aware of their depression, they were fired under various pretexts and in fact
employers were worried about whether their employee will be able to fullfill his
responsibilities or not.
It can be concluded from patients definition of their state as a depressed is a social
construction of various social circumstances. In each phase of mentioned stages, pre-
disease, disease and post-disease different process are in work and causes different
actions. And in each stage patients have different interpretation of themselves and
disease.
Discussion and conclusion:
Narrative story of interviewees about their disease and experience of depression and
anxiety in this study starts with by falling into depression and more sever forms of
depression begins with getting used to it. Patients do not get depressed as a result of
a certain event because as interviewees said the events which caused depression in
them may not result in depression in someone else. This point more precisely shows
that it appears to be constructed. Because patient emphasized on their understanding
of the circumstances and their definition of the situation and even they mentioned
that another member of the family in the same situation did not have depressing
understanding of the same issue. Being depressed exposes the patients into a very
important epistemological question and they ask that question against all common
activities of life. The question is so what? and all answers to this question revolves
around considering life as worthless and meaningless and sometimes it encourages
patients to commit suicide. If somebody has passed this state, he would recover from
the depression.
In interviews, patients were asked about their experience of hospitalization or
visiting a doctor. Two cases were hospitalized during their depression and one of the
cases has got ETC. All patients used anti-depressants. They did not evaluated the
role of psychiatrists positive in process of recovery. Psychiatrists often lack of
empathy with the patients and their behavior toward patients at the best was neutral
and at the worst was destructive and without respect. According to patients anti-
depressants were not effective in improving their conditions and they can be
considered as sedatives. In most cases anti-depressants can reduce patients
consciousness and keep them apart from dealing with their inner issues. In general,
it can be inferred from patients remark that they considered depression as a matter
of dealing with their inner conflict in pre-depression period. As if being ill exempts
them from accepting the common norms. The purpose of this research was
phenomenology of patients perspective about their lived experience of depression.
In fact, constructionism emphasizes on the formation of individuals perception and
image of the disease as well as effect of society on the formation of this image.
Depression is not merely a biological disease that can be cured with anti-depressants
however depression defines itself as a state of mental reaction toward important
issues of social life. Understanding the patient's subjective world about depression
and their experiences reveals that disease is a social construction that is interpreted
through interaction and social circumstances and results in the formation of disease
concept. Individuals have a different perception and interpretation of social
circumstances before their disease. These differences and at the same time being
forced to comply with common norms would enter individuals into a stage that we
call it disease. Patients understanding of disease depends on the severity of his
disease. And after recovery individuals use their experience of disease in his
relationships and reactions.
What is important to say is that at any stage persons perception of outside world has
a very important role in his attitudes toward the concepts of disease, himself and his
relationships with others.