Feeling mentally unwell is the “ new normal ” . A qualitative study on adolescents ’ views of mental health problems and related stigma

Young people suffering from mental health problems is a public health issue, and it is important to listen to adolescents ’ views on the issues that affect their lives. This qualitative study describes adolescents ’ perceptions of the prevalence of and public stigma towards mental health problems among young people. A total of 32 Swedish adolescents, aged 15 – 18 years old, took part in either semi-structured focus groups or individual interviews. The data were analyzed using systematic text condensation, resulting in three themes: Having mental health problems is the new normal; What others think of you affects you; If others lack experience and knowledge, they don ’ t respond well. The adolescents considered mental health problems to be common in young people and a normal feature of their lives. They displayed an in-depth understanding for reasons of the increase in mental health problems in young people, and factors such as pressure from school, stereotypical gender norms, rumors and prejudice were suggested as possible explanations for the increase, alongside improved openness about mental health problems. The adolescents ’ perceptions of the stigmatization of mental health problems were consistent with a trifold definition of stigma, comprising stereotypes, prejudice and discrimination. The adolescents suggested that better education about mental health problems, and more inclusive gender norms, would help reduce stigma and improve young people ’ s mental health.


Introduction
Approximately 13 % of children and adolescents worldwide are suffering from diagnosed mental health problems (Polanczyk et al., 2015;United Nations Children's Fund, 2021) and there has been an increase in the diagnosis and treatment of mental health problems such as ADHD, autism spectrum disorders and affective disorders in young people (Collishaw, 2015).In addition, self reported mental health problems are common among adolescents globally (United Nations Children's Fund, 2021).For example, 19 % of adolescents in 21 countries reported frequently feeling low in a survey from the United Nations in 2021.
Stigma related to mental health problems can have negative consequences for an individual, such as experiencing discriminatory behavior from others and a negative self-image, adding to the burden of the problem itself (Corrigan & Watson, 2002).The stigma of mental health problems has been described using a trifold definition, comprising stereotypes, prejudice and discrimination (Corrigan & Watson, 2002;Fox et al., 2017).
Stereotypes are collective opinions (Rüsch et al., 2005) characterizing people within a particular group with specific characteristics (Fox et al., 2017), for example the public opinion that people with mental illness are considered to be dangerous, incompetent, and weak in character.Believing a stereotype to be true triggers a personal prejudice and emotional reactions (Rüsch et al., 2005).For instance, the stereotype that individuals with mental health problems are dangerous might cause feelings of fear or anger.The reaction of one's own prejudice might then be transformed into discrimination which comprises behaviors that unjustly or unfairly target a particular group, such as people suffering from mental illness.As in the example described above, believing that individuals with mental health problems are dangerous might lead to avoidance or harsh behavior directed towards them (Kaushik et al., 2016;Rüsch et al., 2005).Link and Phelan (2001) also suggest that reactions to stereotypes and prejudice are influenced by the social status of the group being stigmatized.
Public stigma, which is the focus of the current study, presents as the three components of stigma at a population level (Rüsch et al., 2005).The effects of public stigma on an individual can be divided into experienced stigma, anticipated stigma and self-stigma, i.e. internalized stigma (Fox et al., 2017).Experienced stigma is an individual's direct experience of public stigma, e.g.experiencing discriminating behavior from other people based on stereotypes.Anticipated stigma is when an individual worries about being stigmatized, i.e. experiences negative effects even if not directly affected by stigmatization from other people.Self-stigma is internalized stigmatization, when individuals apply public stigma to themselves.Individuals experiencing self-stigma believe they have stereotypical characteristics, resulting in self-prejudice, and leading to low self-esteem and low self-efficacy.
Young people with mental health problems are exposed to stigmatization from both adults and other young people (Kaushik et al., 2016), and it has been suggested that the trifold definition of stigma is also applicable to young people (Silke et al., 2016).In terms of stereotypes, it is common for young people to embrace negative opinions about those suffering from mental health problems (Svirydzenka et al., 2014) and to link such problems to intellectual disability (DeLuca, 2020).In terms of prejudice, young people can perceive adolescents with mental health problems as dangerous or not taking personal responsibility for their situation (Kaushik et al., 2016), which is associated with discriminatory behavior (Silke et al., 2016) such as distancing (Kaushik et al., 2016), and bullying (Ferrie et al., 2020).
Despite the huge public health impact of adolescent mental health problems, relatively few studies have investigated adolescents' views on these problems, especially in terms of perceived prevalence and public stigma (Armstrong et al., 2000;Teng et al., 2017).
It is important to listen to adolescents' voices about issues related to mental health problems, to provide insights that can inform interventions and policies that aim to improve their mental health (Sawyer et al., 2012).
In another study, we have described adolescents' views on the concepts of mental health and mental health problems (Hermann, Durbeej, Karlsson, & Sarkadi, 2022).The aim of this study was to describe adolescents' perceptions of the prevalence of, and public stigma towards, mental health problems among young people.Two research questions were addressed: 1) How do adolescents perceive the prevalence of mental health problems among young people in their society?
2) How do adolescents perceive public stigma towards mental health problems among young people in their society?

Participants
A total of 32 adolescents (14 boys and 18 girls), 15-18 years old, took part in semi-structured interviews, either individually or in focus groups, during October to November 2020.
A purposive sampling strategy was used.After obtaining permission from the head teachers, the participants were recruited from three lower and two upper secondary schools in different areas of Gotland (Sweden's largest island with approximately 2,500 inhabitants in the 15-18 years age group).In Sweden, grades 7 to 9 (age 13-15 years) are defined as lower secondary school, which is mandatory.Upper secondary school is voluntary and corresponds to grades 10 to 12 (age 16-19 years).In upper secondary school, students choose to attend either a vocational program or a theoretical program, leading to qualification for higher education.
The first author visited a total of nine classes in both lower and upper secondary schools, to provide information about the project and to recruit participants to the study.In the upper secondary schools, participants were recruited from both vocational and theoretical programs.Forty-one students volunteered to participate; however, three students changed their mind prior to the individual interviews and, because of COVID-19 pandemic restrictions, one focus group of six students had to be cancelled.The final sample of participants therefore comprised adolescent students, 18 from lower secondary schools and 14 from upper secondary schools.

Interviews
Five focus group interviews and five individual interviews were conducted.The individual interviews were held to complement the focus groups and to add a further dimension to the data (Lambert & Loiselle, 2008).Table 1 presents numbers and gender of the participants in each interview.
All the interviews were held in two parts, conducted either on the same day with a break between them or on different days within the same week.On average, each focus group session lasted 57 min (i.e.min for the two sessions), and each of the individual interviews lasted 38 min (i.e 76 min for the two sessions).The first author moderated all the focus groups and conducted all the individual interviews, supported by a semi-structured interview guide (Table 2).
In addition to questions about views on stigma and the prevalence of mental health problems in young people, the interview guide included questions on the concepts of mental health and mental health problems as well as measuring those concepts.This paper reports on the perceived stigma towards and prevalence of mental health problems; the results

Table 1
Numbers and genders of participants in the focus groups (FG) and the individual interviews (I) (n = 32).
Girls Boys 18 14 V. Hermann et al. regarding conceptual views on mental health, mental health problems are reported in a separate paper (Hermann, Durbeej, Karlsson, & Sarkadi, 2022).The interview guide was pilot tested with the first focus group and, after evaluation by the authors, found to be appropriate without modification.Thus, the data from the first focus group were included in the overall dataset of the study.
An observer attended each of the focus group sessions, and after each session reflected on the interview situation with the moderator.

Analysis
The interviews were audio recorded and transcribed verbatim by the first author.The data were found to be rich but not too redundant, and were analyzed inductively in four steps according to the systematic text condensation method described by Malterud (2012).
The four steps of the analysis were: 1) All the authors read the transcripts to glean the essence of the participants' descriptions.Preliminary themes were discussed by the authors until a consensus was reached.2) Meaning units were marked in the transcripts and sorted into the preliminary themes and code groups by the first author.In addition to the systematic text condensation procedure, (Malterud, 2012) interactions in the meaning units from the focus group discussions were also marked during this step.The following types of interaction were sought and marked in the margin of the text: agreement or disagreement about statements, nuancing of another participant's statement, a participant's change in opinion, different preconceptions or knowledge, dominant repetition of an opinion from a participant, silencing of a participant's opinions and raised level of energy in the group.
3) The first author condensed the meaning units in each code group into subgroups, summarized as synthetic quotes, written in first person format, according to Malterud's (2012) descriptions.In addition, the marked interactions in the meaning units (in step two) were summarized.All the authors then discussed and adjusted the themes, code groups and resulting categories in accordance with the procedure of systematic text condensation (Malterud, 2012).4) In accordance with the last step in the systematic text condensation procedure (Malterud, 2012) the first author formulated an analytical text for each theme, with categories as subheadings, including results originating from the focus group interactions.The results were then validated against the original transcripts.After all the authors and other research colleagues had reflected upon the results, some adjustments were made.

Research ethics
The Swedish Ethical Review Board (reg.no.2020-03300) granted approval for the study.Head teachers and teachers were given written information about the study.After oral and written information had been provided, students who wanted to participate in the study gave their written informed consent.According to Swedish law, adolescents are allowed to consent to participate in research for themselves from the age of 15, without parental consent, if they are capable of understand given information and the consequences of their participation (SFS 2003:460).All students were 15 years or older and considered to have the cognitive maturity to be capable to give their informed consent, and therefore parental consent was not required.The students were told they could withdraw their participation at any time without further explanation.
In reporting the results, pseudonyms are used instead of the real  names of the participants, to protect their identity.All personal identifying details have been removed.

Results
The systematic text condensation resulted in three themes, each with two subcategories (Table 3).

Mental health problems are a part of life
The adolescents described mental health problems as being a natural part of life as well as an increasing problem in society.
It's kind of pretty common among the majority of adolescents.It'll always be many in a class who have some kind of mental health problems, even though you don't know it.(Jennifer) They considered mental health problems to be common among young people overall as a result of pressure from school, perceived norms and social media.
I think there's an increase in mental health problems nowadays.It's because all adolescents live under such great pressure, both from home and then social media and how to behave and which norms to follow.(Jim) Some adolescents also mentioned an elevated risk of experiencing mental health problems because they were surrounded by friends with mental health problems.They considered mental health problems to be "contagious".More specifically, the adolescents described a risk of starting to feel unwell and developing own mental health problems when a friend had such problems.This risk was explained by strains related to negative feelings when seeing a friend suffering and to being overwhelmed of the thought of helping a friend with mental health problems, it being perceived to be their responsibility.Further, they described that the feeling of helplessness might trigger own mental health problems.Estelle: -How others feel kind of affects you (…).Kate: -It's not easy (…) you have to be there but you can't like be there absolutely the whole time and be all absorbed by that person.
The adolescents suggested mental health problems were conditions that anyone could have, and that such problems were caused by many different factors.Mental health problems were issues they had to deal with, and they stressed that no one should be blamed or judged for having such conditions.
The people with mental health problems who I've met (…), they have, or like, live with something bad.They aren't (…) bad people.As an exception, one participant stated that you might be blamed for your mental health problem, if you turn a minor issue into a major issue.There was also an engaged discussion in one focus group that held diverse opinions on whether those with mental health problems could "pull themselves together" and get well if they were really motivated: Jennie: -Because your will is kind of a pretty strong thing.If you really want something you can always succeed, sort of (…) Evelyne: -But it depends on what kind of personality you have.If you're a really driven person and very goal orientated person it might be easier (…) Liz: -Okay, no but I don't think it's got so much to do with personality.I think it's more linked to how deep down in the dark depths you are (…) Sure it might help if you're a really determined person (…) but I think for sure there is a point when all you feel is that you cannot cope anymore despite being a determined person.
However, the adolescents agreed that it is essential that prejudice against people with mental health problems is eliminated.They gave examples of beliefs or expressions that they found problematic, e.g. that people with mental health problems in general are "crazy", dangerous to others or unpredictable.In addition, they stressed that the impact of someone's mental health problems on other people depends on the condition, symptoms and the relationship between that individual and the others.
When reflecting on whether people with mental health problems are dangerous to others, one boy stated: It kind of depends entirely on, yes, what position you have in society.Like, if the prime minister turns out to have schizophrenia or something, then he would be a very big danger to the rest of the country, but like that depends on what part you play in other people's lives (…) It also kind of depends on the disease (…).Because if you are bipolar, for example, then maybe, yes then you might be a danger to others, if you're a parent and you yourself are bipolar and do not treat it.(Peter)

Views on mental health problems have varied over time
Many of the adolescents recognized that they had gained a better understanding of the concept of mental health as they matured from childhood to older adolescence.In addition, they stated that their own generation has a greater openness, knowledge and understanding about mental health problems than previous generations.They mentioned that the recorded increase in mental health problems in young people is the result of fewer taboos about mental health problems and increased access to help, compared with the past.Furthermore, some of the adolescents perceived an ongoing societal change towards more openness about mental health problems, which would probably result in even fewer taboos about mental health problems in the future.
People who are like 30 plus, they usually don't know anything (…) Because it didn't exist in the same way when they were young.Then it was like something odd, that the idea was made up.But then there's this golden age (…) between 15 and 30.There I constantly find people who have kind of been through things themselves, get facts about this themselves, they talk about self-care (…) I've had conversations at school about suicidal thoughts (…) totally random (…) with some classmates (…) I don't think it would have happened 10 years ago (…) it's something that's starting to (…) be discussed.(Celine) Some participants reflected upon differences in past and present living conditions affecting the prevalence of adolescent mental health problems.One explained: In the old days, you had to go to school (…) work with the family to help (…) We here have the luxury of the world and can just go home and lie down and look at the phone.Just like, what are we sad about when they were much worse off (…) However, they had nothing to compare with.(Liz)

Stereotypic norms cause mental health problems
According to the adolescents, norms and ideas about how people should be and behave, such as traditional gender norms and prejudices linked to ethnic background and mental health status, could cause mental health problems.They argued that those exposed to excluding norms and prejudice will experience feelings of exclusion or inequality, which will have a negative effect on their mental health.Examples of labels that were described as unhelpful were individuals with mental health problems being called weak or attention seeking.Some adolescents mentioned the potential risk of falsely labelling others with no mental health problems as having a mental condition.
If (…) people tell you every day like "you're not mentally well" (…) or like put a label on [that you have mental health problems when you don't have them] (…) that will make you feel unwell.It kind of becomes a chain reaction and you get (…) worse and worse.(Kate) Some participants also recognized that young people with mental health problems might be disregarded because of the preconception that feeling unwell is a normal state of mind during teenage years.
I think when you're in that age [15 years old] (…) and feel unwell [have symptoms from mental health problems] (…) I think society is kind of "It'll be better over time" and it's like nonsense when you're young.(Oscar) Stereotypical gender norms were mentioned in the individual interviews and vigorously discussed in each of the focus groups and were highlighted, in consensus, to be a causal factor of mental health problems.The adolescents found the macho norm, expecting men to be strong and insensitive, unlike women, was preventing boys from expressing their feelings and getting support and help when needed.This thing with norms (…) everyone needs to express their feeling and not hold everything inside.There are fewer boys who deal with their problems because it's not the norm for a boy to go and talk to someone [professional] while girls does that a lot.(Eddie) In addition, stereotypic gender norms were seen as the reason for girls often being treated as weak and over-sensitive, or objectified.
This macho norm about not to tell anyone (…) causes more suicide among men because they don't talk to anyone about it and then no one can stop it.At the same time (…) it feels like we [women] are seen as victims in a way and have to put up with a lot of things (…).Maybe that's why it's more common with mental health problems among women.(Celine) Furthermore, the participants recognized boys as having fewer social contacts than girls and not paying as much attention to their friends' mental health as girls.
I think girls are more open about it.They've got someone to talk to.Or so do boys too, but they're not aware of it.Girls, I think girls dare to open up more if they feel bad or something.Because it's normalized for girls to show emotions.(Martin) At the same time, some adolescents reflected upon the fact that boys can be sensitive and might talk about feelings with their friends on a one-to-one basis rather than in a group.
Several of the adolescents in the girl-only focus groups mentioned that these gender norms cause girls to have more mental health problems than boys.However, other girls did not agree and instead suggested that boys have more mental health problems.This was also highlighted strongly by the majority of the boys, both in the focus groups and in the individual interviews.Thus, both girls and boys argued that stereotypical gender norms and stigma of mental health problems need to be reduced to improve adolescents' mental health.They also demanded help for all adolescents in need of support when being open about their needs.

Living in a small geographical area has an impact on your mental health
The adolescents felt that the fact that they lived on a relatively small island, where everybody knows everybody, was a causal factor for mental health problems and spread of prejudice against mental health problems.Discussions about this were very lively, and the adolescents agreed, both in the girls-only and boys-only focus groups, that rumors spread quickly and it was impossible to be anonymous.Some of the participants even suggested that the inability to be anonymous was causing young people wanting to move away from the island.
But like what you wear (…) Just because everybody knows everybody, for example if I was to kind of turn up in this whole EMO-style at Öster [in the centre of the town Visby] out of the blue.Of course every-one would know in no time and like (…) "Is she starting to feel unwell?" (…) And here I would say that it's like you're expected to be in a certain way.(Kate) Several participants described the lack of leisure activities for adolescents on Gotland, and the distance to mainland Sweden, as curtailing their opportunities, causing a feeling of isolation and therefore affecting their mental health.
We have beaches, a lot of nice beaches absolutely, but we have (…) nothing to do.People need to have something to do together.(Elliot) We live on an island and we are kind of physically isolated from maybe the rest of the country (…) When I've been on the mainland (…) I always feel like a stranger.(Peter) While some adolescents did mention positive aspects to living in a small place, for example living in a safe environment where it is easy to detect mental health problems in others, those aspects were not highlighted as much as the negative aspects.There was, however, a disagreement between the adolescents on whether mental health problems were more common on Gotland compared with mainland Sweden.Some adolescents suggested that mental health problems were more common on Gotland because of the isolation and rumor-spreading.Others suggested that such factors also exist in small places elsewhere and therefore questioned whether mental health problems were more common on Gotland.

It's easy to be prejudiced against things you aren't familiar with
The adolescents suggested that people's previous experiences and knowledge influence their reactions to individuals with mental health problems.They stated that it is easy to be prejudiced against something unfamiliar, which, in turn, can lead to fear and misconceptions that cause discriminating behavior (e.g.avoidance, exclusion or rumor spreading) towards people with mental health problems.While the participants recognized prejudice and discriminatory behavior linked to mental health problems across the whole spectrum (e.g. from anxiety symptoms caused by long-term stress to severe mental illness), in general they found young people to be more familiar with and less prejudiced towards more common conditions than uncommon conditions.One girl's response exemplified this: I think it might be easier for young people to call someone with schizophrenia insane than someone being depressed, kind of.In that way one can be more prejudiced against things you're not as familiar with, maybe (…) There I think adolescents are quite understanding when it comes to depression, anxiety and such.(Sara) Some participants also recognized that it is common among adolescents to label people with mental illnesses like schizophrenia as dangerous or crazy because of their representation in movies.
One maybe has the image that this person is completely crazy.You think it's that movie character with like 24 different personalities.(David)

Lack of knowledge is a barrier to helping others who don't feel well
The majority of the adolescents stated that most people actually want to help those with mental health problems.
V. Hermann et al.I think there's more people who care than people who don't care (…) You want to do the best you can, but you don't understand.And then those who don't care at all are so loud so it feels like there are so few who care and are there for you.(Elliot) The adolescents thought a lack of knowledge about mental health problems was the major barrier to helping others.They felt that many people do not know how to recognize when help is needed and how to act, and therefore might feel incompetent and ignore someone in need, to avoid worsening the situation.
In addition, the adolescents identified the normalization of mental health problems as a risk factor for not taking action when someone is not feeling well.
Jennifer: -I think it's been so normalized that like if someone would have an eating-disorder sort of or something like that it just gets like … Susie: -Just eat (…) Jennifer: -Yes, just eat or like that or like it's become so normalized that it's nothing special, like everyone is having it.People see it like that, kind of.Liam: That's like true (…) It's too common to like take on.If you have ten friends and half of them feel unwell then you can't care about the others who you don't know.
The risk of starting to feel unwell themselves when supporting a friend with mental health problems was also suggested as a barrier.The adolescents felt it might be hard to know how to handle a complex situation.
Estelle: -You don't want to end up in that situation yourself.Like you don't want to feel unwell.Kate: -Exactly.So you might find it as a behavior like you sort of step to the side (…) Denise: -It's like you need to be there but still you can't be there all the time and just get all caught up with that person (…) You also need to think of yourself (…) No it's sort of tricky knowing what to do.

Discussion
This study has revealed how the interviewed adolescents perceive the prevalence of, and public stigma related to mental health problems among young people in society.

Mental health problems are the "new normal"
According to the adolescents participating in the study, mental health problems are a normal part of their lives.They considered mental health problems to be common in young people and suggested that anyone could be afflicted.These results are in accordance with previous quantitative research by Williams and Pow (2007), who, in a crosssectional study, found that 90 % of adolescents believed that anyone could experience mental health problems.
While the adolescents recognized mental health problems as an increasing burden for young people in society, they also had a nuanced understanding of the factors that may explain this trend.In line with the literature (Collishaw, 2015), the participants attributed the rise in mental health problems to societal changes.Their perception of pressure to perform in school as a causal factor for increased mental health problems among adolescents agrees with findings from the Public Health Agency of Sweden (2018).Their suggestion that improved openness about mental health problems is an additional factor influencing the increase in diagnoses has also been proposed by (Collishaw, 2015) and Wickström and Lindholm (2020).
The adolescents recognized potential risks to mental health problems being the "new normal".One risk identified was falsely labelling those without mental health problems as having a mental health condition.Conversely, problems presented by young people with mental health problems might be disregarded because of a preconception that feeling unwell is a normal state of mind for young people these days, and that "all" young people have mental health issues.

The (bright?) future of public perceptions
The participating adolescents noted the presence of stereotypical opinions about mental health problems, prejudice and discriminating behavior in today's society, such as avoidance and reluctance to help people with mental health problems.They considered young people's behavior towards those suffering from mental health problems to be based on a personal understanding of mental health problems.Lack of knowledge and experience of mental health problems were explained by the adolescents as reasons for internalizing societal stereotypes into personal prejudiced attitudes, causing unwanted behavior.This is consistent with the trifold definition conceptualizing the stigma of mental health problems based on stereotypes, prejudice and discrimination (Corrigan & Watson, 2002;Fox et al., 2017).Hence, the findings in the current study adds weight to the suggestion that the trifold definition is applicable to adolescents (Silke et al., 2016).
Also in line with previous literature (Aguirre Velasco, Cruz, Billings, Jimenez, & Rowe, 2020;Calear, Batterham, Torok, & McCallum, 2021;DeLuca, 2020;Gulliver, Griffiths, & Christensen, 2010;Kaushik, Kostaki, & Kyriakopoulos, 2016;Radez et al., 2021;Ferrie et al., 2020), the participants described public stigma as negatively affecting young people's mental health.For instance, they suggested that avoidance and reluctance to help someone with mental health problems might lead to an unwillingness to seek help for your own mental health problems.Although the adolescents linked avoidance of peers with mental health problems with prejudice, they also gave examples of avoidance without persisting prejudice.It was evident in their responses that they wanted to help their peers suffering from mental health problems, but were unable to do so because of a lack of knowledge or time.Moreover, they described the risk of being negatively affected by peers feeling unwell as a barrier to helping them.This suggests that support is needed not only for young people with mental health problems but also for their peers, to improve young people's mental health overall.
The participants in all the focus groups and in almost all the individual interviews viewed stereotypic gender norms as negatively influencing youths' mental health.Girls' mental health being most negatively influenced by societal gender norms is reflected in findings by Landstedt et al. (2009) with other Swedish adolescents.Landstedt and colleagues (2009) linked their results to the presence of power relations, where men are viewed as superior to women and girls find it stressful fulfilling the expectations of stereotypic feminine ideals.This was also reflected in the current study.However, both boys and girls in our study also supported the opposite opinion, that gender norms affect boys more than girls.Overall, the participants believed that a transition from traditional to egalitarian gender norms would reduce mental health problems for young people.This has also been proposed by King and colleagues (2019), who found, in a longitudinal study of adolescents in Australia, that egalitarian gender norm attitudes were associated with better mental health.
Moreover, the participants believed older adolescents were more accepting of mental health problems than younger children, because of their greater experience and knowledge.This view has been both supported and rejected in previous studies (Kaushik et al., 2016).Interestingly, the adolescents also stated that adults are less open about mental health problems and have less knowledge and more prejudice compared with younger people.Corrigan and colleagues (2012) reported that, in order to reduce the stigma of mental health problems among adults, contact with people with mental illness can be more effective than education about mental health problems.In contrast, for young people, education has been proposed as the most effective method for reducing V. Hermann et al. stigma (Corrigan et al., 2012).
The participants considered mental health problems to be something that is treatable and, in line with previous research (Bradbury, 2020;DeLuca, 2020).They identified increased knowledge and contact with people suffering from mental health problems as drivers for reducing the stigma of mental health problems.Overall, the adolescents considered increased openness, reduced prejudice about mental health problems and reduced prevalence of stereotypic gender norms as important factors for improving young people's mental health.Their responses conveyed hope that societal change towards improved openness about mental health problems might eventually lead to a future without stereotypical gender norms and prejudice against mental health problems.

Methodological considerations
The study has both strengths and limitations.Overall, qualitative methods are considered suitable for exploring adolescents' experiences of stigma associated with mental health problems (Swords et al., 2021).The combination of different interview methods, as has been used in previous studies (Armstrong et al., 2000;Johansson et al., 2007;Teng et al., 2017), provided a richer dataset.It was also beneficial that the first author (who interviewed the participants) had experience of listening to and talking with various people, having been a nurse and midwife.Because there is an imbalance in power relations between researcher and participants (Kreuger & Casey, 2015), the interviewer tried to make sure that the participants felt at ease, and aimed to provide a comfortable and welcoming environment.For instance, the participants were involved in informal conversations prior to the interview, snacks and drinks were served, and the interviews were held in a private room.
The purposeful sampling ensured participant heterogeneity regarding gender, age, educational trajectory in upper secondary school, geographic location and governance of schools attended, making the results of some relevance to other scenarios.However, caution is needed if the results are applied elsewhere, as other groups might have different knowledge of, interests in or experiences of mental health problems and stigma compared with the adolescents who volunteered to participate in this study.A lack of data on the participants' prior experiences of mental health problems, stigma and ethnic backgrounds is a limitation of the study.In addition, Gotland is a rural area with a relatively small proportion of residents with an ethnic background other than Swedish, which could limit the transferability of the results to, for example, urban settings.
The analytical process carefully followed the steps stipulated by Malterud (2012).A clear decision trail was kept, using notes and tables depicting different versions of the final results.The application of reflexivity (Malterud, 2001) was particularly important in avoiding bias, because the first author works on public health strategies for Gotland, and collected the data, transcribed the interviews and led the analysis.The authors also held theoretical preconceptions about adolescents' mental health problems.Therefore, reflexivity focused on interview technique and researcher interpretations in the discussions held by the author group, to both minimize the risk of research bias (Lambert & Loiselle, 2008) and strengthen the trustworthiness of the study (Polit & Beck, 2022).More specifically, all the authors read the transcripts from the first focus group interview before the other interviews were conducted.The interview technique was then discussed, focusing on the moderator's ability to support the adolescents in sharing their thoughts without interfering more than necessary.Directly after each focus group, the moderator and the observer reflected on the moderator's performance during the interview process.During the analysis, the authors' perceptions of the data content were actively questioned in relation to what the participants had actually said.During the sorting of meaning units, and condensation and formulation of the analytic text, the first author repeatedly went back to the transcripts to verify whether the results of the analysis corresponded with the original data.In addition, in discussions about the condensates and final themes and categories, the first author was occasionally asked by the other authors to develop or summarize the meaning of alternative wordings to check for biased formulations.

Conclusion
In this qualitative study, adolescents described the high prevalence of mental health problems as the "new normal" for their generation.They had a complex understanding of the various factors that could explain the increase in mental health problems in young people.Their perception of the stigmatization of mental health problems was consistent with the trifold definition of stigma, based on stereotypes, prejudice and discrimination.

Recommendations
Even though these findings represent the views of Swedish adolescents on Gotland, they provide insights that should be useful when highlighting mental health problems in young people as a general public health concern.Based on the findings of this study, the authors wish to emphasize the necessity of intervention in three key areas: 1) Better education in general, among young people and adults, on mental health problems and accessible information about how to help those suffering from mental health problems.2) Emotional support for adolescents with friends suffering from mental health problems.3) Involvement of young people in discussions held in different societal settings, such as in school, on how to reduce stereotypical gender norms and prejudice against mental health problems, rather than merely educating adolescents about their prevalence.
Kate: -I think it's very contagious.(…) If Denise would fell unwell [have mental health problems].(…) I feel worse (…).If (…) my friends self-harm and want to kill themselves, of course I'll not feel well (…).
(Peter) Like no matter who you are we've got the right to feel unwell [have mental health problems].(Lucy)

Table 2
The interview guide.
Questions, part one -What made you agree to participate in this study?-What is the first thing that comes to mind when I say mental health problems?-What is the first thing that comes to mind when I say mental health?-Whatdoyouthink is the difference between (good) mental health and mental health problems?-Wecanthinkdifferentlyabout people who have mental health problems.What do you think about that?-Regarding what we've been talking about, how do you think the situation is on Gotland? -If you had a minute at most to tell me the most important thing that has come up in this conversation, what would you say? -How well do you think I/the observer has captured what you've been talking about?[after the observer/interviewer has summarized what has been said in the interview] -Is there anything we have not talked about that should have been included?-Isthereanythingyouwant to add to what you've already told me? Questions, part two -Have you thought of anything since our last conversation that you want to add? -What do you think we should ask adolescents in a survey about (good) mental health and mental health problems?-Whatshouldwedefinitelynot miss out? -Do you think these questions would work?[showing questions from specific instruments to measure positive mental health, symptoms of mental health problems and stigma towards people with mental health problems.]-Howdidyoufeelanswering these questions?-What do you think of these questions?-How well do you think I/the observer has captured what we've been talking about?-Is there anything you want to add?

Table 3
Themes and categories arising from the analysis.
It's easy to be prejudiced against things you aren't familiar with Lack of knowledge is a barrier to helping others who don't feel well V.Hermann et al.