2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

To Improve Adolescent Mental Health, We May Need to Address Adverse World Events

It appears that the prevalence of mental disorders among adolescents has been increasing. The National Survey of Drug Use and Health (NSDUH) shows an increase in major depressive episodes.1 A study about children and adolescence who are eligible for SSI by virtue of mental disabilities found an increase in most disorders between 2004 and 2013.2 And CDC “surveillance during 1994-2011 has shown the prevalence of [mental health] conditions to be increasing.” 3

There is some dispute about whether the apparent rise in prevalence reflects increases in mental illness or in its diagnosis. But the documented rise in adolescent (13-21) suicide rates from 7.8 to 10.1 per 100,000, a 29% increase since the turn of the 21st century,4 lends credibility to the claim that mental illness has increased.

Why the Increase?

One common speculation is that there has been a decline in mental health services in this century. But that is not the case. The use of mental health services by adolescents has increased.1 Funding of mental health services has also increased. Whatever the ups and downs of state mental health funding, the expansion of Medicaid and the requirement to cover behavioral health under the Affordable Care Act have resulted in millions of people getting additional coverage and some increase in service utilization.

So, if there has not been a decline in mental health services, why is the prevalence of mental disorders among adolescents up? Clearly, other forces are at work.

Perhaps it is the factors that are commonly called “social determinants”, most notably poverty, violence, and “adverse childhood experiences” (ACEs).

Could be, but in a recent survey conducted by the Harris Poll for the American Psychological Association5, adolescents themselves gave different and interesting answers.

The survey asked about the mental health of people of different generations—Gen Z (15 -21), Millenials (22-39), Gen X (40-53), Baby Boomers (54-72), and “matures” or older adults (73+).

According to the survey, Gen Z (the adolescents) “are most likely of all generations to report poor mental health and … also significantly more likely to seek professional help for mental health issues.” They seem, that is, to experience more distress than older generations, more feelings of depression and anxiety, and to use mental health services to deal with them.

And what are the sources of their distress? The Gen Z’ers themselves point to world events that are making headlines—gun violence; sexual harassment and assault; treatment of immigrants, especially separation of families and deportation; the economy and discouragement about having a secure financial future; housing instability; drug problems in their families; racial discrimination; the current, divisive and vituperative political climate; their skepticism about the future of America; and more.

Clearly, there has been much to fuel concern about the state of America and the world since the beginning of the 21st century—through the administrations of Bush, Obama, and now Trump. The rise of terrorism, the decline of the environment, the possible spread of nuclear weapons, increasing disparity, rising racial tensions, the plight of refugees, and more—all contribute to the gloominess of most of the people I know and to fear for the well-being or even survival of future generations. But do these big social issues contribute to more diagnosable mental illness?

There are reasons to be doubtful. Many people who experience depressive or anxiety disorders grasp for reasons that might explain their unhappiness or fear and often don’t come up with accurate explanations. So, Gen Z’ers could be wrong about what’s causing stress in their lives.

In addition, distress and mental illness are not one and the same. The Gen Z’ers could be right about their sources of stress, but it could be wrong to assume that a rise in stress is contributing to a rise in mental illness.

And, maybe, as I said at the beginning, prevalence of mental disorders is not on the rise, just its diagnosis. Or maybe it’s organic. Or, maybe, as many people seem to think, it’s social media and screen time.

A digression here about social media. 55% of Gen Z’ers reported that social media was a primary source of support when they are distressed. They also reported that it could be a source of distress, due to cyber bullying and the like. So, in their experience social media are a mixed bag.

Back to the question of whether world events are contributing to a decline of mental health. Possibly not, but if we use the usual simplistic model of mental illness as the outcome of innate vulnerability and social and psychological stressors, it would make sense that the state of the world is having an impact on the state of mental health—adolescent and adult.

And this would have important implications for mental health policy.

First, it raises doubt about whether increasing the availability of mental health services, improving their quality, promoting integration of service systems—all high on mental health policy agenda—will have a significant positive impact on the prevalence of mental disorders, suicide rates, overdose deaths, and so forth.

I am not suggesting that the elements of the current behavioral health policy agenda should be abandoned. I have been advocating for them for the past 40 years and will continue to do so. And I believe that mental health services can relieve the suffering of many individuals. Whether achieving our goals would result in widespread improvement of adolescent mental health is another question entirely.

Second, the probability that world events have a significant impact on mental health suggests that our current prevention agenda6 does not go far enough. Again, I am not suggesting that we should abandon this agenda. It’s important to mitigate the impact of poverty, violence, and adverse childhood events. It’s important to provide support for parents who struggle to do what is right for their kids. It’s important to provide early intervention and better education. But it may not be enough.

It may be that child and adolescent mental health advocates need to add adverse world events to their list of concerns, not just because the future of humanity may depend on the outcome of these issues, but more narrowly because the mental health of the next generations will fall, or hopefully rise, with the outcome.

Of course, taking on the flaws of the world we live in may be far too much to do. It takes enormous effort to pursue our current agenda. Our successes, and there are quite a few, have been hard won. Some advocates are called “tireless” because they are persistent. Most, I suspect, are in fact tired but dogged.

Nevertheless, long-term improvement of the mental health of our youngest generations may depend on entering the fray to fix the world and ensure that the generations to come will have the life we hope for them.

Michael B. Friedman, LMSW is Adjunct Associate Professor at the Columbia University School of Social Work. He can be reached at mf395@columbia.edu. His writings can be found on the internet at www.michaelbfriedman.com.

References

  1. Boat, TF and Wu, JT Editors (2015). Mental Disorders and Disabilities Among Low-Income Children. The National Academies Press.
  2. Perou Ruth et al (2013). Mental Health Surveillance Among Children – United States, 2002-2011. Centers for Disease Control and Prevention. Mortality and Morbidity Weekly Report. May 17, 2013.
  3. Substance Abuse and Mental Health Services Administration (2018). “National Survey on Drug Use and Health: Comparison of 2008-2009 and 2016-2017: Population Percentages.” https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHsaeTrendTabs2017/NSDUHsaeLongTermCHG2017.pdf
  4. Centers for Disease Control and Prevention. WISQARS: Fatal Injury Data. Accessed November 29, 2018.
  5. American Psychological Association (2018). Stress in America: Generation Z. https://www.apa.org/news/press/releases/stress/2018/stress-gen-z.pdf

6.            Warner, KE and Boat, TF et al (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. National Research Institute and the Institute of Medicine of The National Academies.

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