OBJECTIVES: This study explored tensions between biomedical and psychosocial illness models and between the public health goal of stigma reduction and patients' perceptions of helplessness. Patients' etiological beliefs and use of language are considered as possible pathways to improved care.

METHODS: Qualitative and quantitative data were obtained from 18 adults attending a mood disorders support group in Dublin, Ireland.

RESULTS: Respondents reported feelings of helplessness concerning the occurrence of depressive episodes. When describing episodes of wellness and depression, respondents used a "light switch" metaphor to indicate this lack of control. For several respondents, acceptance of biomedical causality was linked to helplessness. In contrast, spiritual beliefs offered hope.

CONCLUSIONS: Alleviating patients' sense of responsibility may reduce their guilt, but patients' perceptions of illness uncontrollability may diminish their sense of agency, reinforce depressive attributional styles, and undermine overall treatment outcomes. Communication and the patients' involvement in decisions are vital to treatment.