Adolescent Mental Health and Well-Being: A Public Health of Consequence, February 2024

Based on 2021 Centers for Disease Control and Prevention (CDC) data, more than 30% of US adolescents experienced poor mental health during the COVID-19 pandemic. Although availability of recent global data is limited, according to data collected as part of the Institute of Health Metric’s 2019 Global Burden of Disease study, one of seven adolescents aged 10 to 19 years experienced a mental health condition worldwide (https://ghdx.healthdata.org). Depression, anxiety, and behavioral disorders account for the majority of adolescents’ mental health burden and can negatively influence individual as well as collective health and well-being during this crucial period of development. Yet, implementation of effective policies and programs to prevent mental health burdens and to support those experiencing mental health conditions is uneven at best and wholly absent at worst. In addition, suicide is the fourth leading cause of death among adolescents and young adults aged 15 to 29 years worldwide. What these overall prevalence estimates mask are variations across countries, particularly variations driven by differences in data quality, availability of treatment services, and importantly, knowledge about mental health burdens and stigma associated with mental health illness.

Moreover, as we emerge from the social and physical distancing required during the COVID-19 pandemic, we also emerge into an era when the social isolation experienced by adolescents during the pandemic is compounded by growing fears and anxieties. Experiencing and even observing the growing burden of political, social, economic, and environmental adversities—such as an increasing number of political and military conflicts worldwide, forced migration, gun violence, restrictions on sexual and reproductive rights, increasing homophobia and transphobia, greater economic instability, and worsening climate crises—are strong social and structural drivers of mental health burdens among adolescents. Among adolescent girls of color and those who identify as gay, lesbian, bisexual, transgender, queer, and nonbinary, these adversities can be exacerbated by experiences of racism, discrimination, stigma, bullying, and adverse childhood events that amplify their risk of experiencing mental health burdens.

In this Public Health of Consequence, we focus on recent findings published in AJPH describing difficulties in accurately, appropriately, and consistently measuring mental health burdens among adolescents globally and highlight current efforts to provide more appropriate diagnostic tools for adolescents. Furthermore, we highlight sociocultural frameworks more relevant for adolescents as well as culturally tailored and age-appropriate interventions that may be effective at reducing or alleviating the harms associated with mental health burdens. Recognizing the importance of the social, political, and environmental shocks that adolescents are facing and navigating will allow public health practitioners to increase access to effective treatment and support services as well as prevention programs for those most vulnerable.

ESTIMATING MENTAL HEALTH BURDENS

Liu et al. used data from the 2022 Household Pulse Survey, fielded by the US Census Bureau, to provide estimates of parent-reported mental health symptoms among adolescents aged 18 years and younger.¹ Their findings, although based on parental report, indicate that 34.5% of adolescents experienced a mental health symptom (e.g., “feel anxious or clingy” or “feel very sad or depressed”) in the past four weeks. Although these data are derived from parental reporting and are subject to information bias and also reflect a very short time frame (the previous four weeks), they are comparable to estimates obtained in the CDC’s Adolescent Behaviors and Experiences Survey. These comparable estimates may suggest that we can rely on parental reporting to estimate adolescent mental health burden. However, proxy (e.g., parent) responses should be employed with caution. In addition, the types of measures used and time frames ascertained will affect the estimates of mental health burdens in adolescents. What these findings do call for is the consistent use of validated diagnostic measures in all population-based surveys that ascertain data on adolescent mental health, as the use of symptom-based scales in population-based surveys are unlikely to provide accurate estimates of true mental health burdens.

In addition, the development and use of consistent diagnostic measures of mental health burden in adolescents living in low- and middle-income countries (LMICs) face further challenges. Specifically, ensuring their cultural and linguistic appropriateness as well as their clinical relevance is required for diagnostic accuracy. The need for appropriate diagnostic tools cannot continue to be ignored given the growing burden of mental health conditions worldwide. To this point, a part of the Global Early Adolescent Study (https://www.geastudy.org), the National Adolescent Mental Health Surveys (NAMHS) serves as an example of a successful model of developing and implementing mental health assessment among adolescents in three distinct LMICs: Kenya, Vietnam, and Indonesia (https://bit.ly/3uoZhQV).

INTERVENTIONS THAT MEET ADOLESCENT NEEDS

Beyond accurate diagnostic tools for adolescent mental health burdens, the public health community need to ensure community engagement and buy-in as well as mental health service delivery capacity building to meet the mental health needs of adolescents. Recognizing that untreated mental health needs among adolescents are significant drivers of mental and physical health burdens in adulthood, particularly for minority adolescents, Hampton-Anderson et al. posit a sociocultural conceptual framework for reducing the disparities in mental health treatment utilization among Black adolescents.² The three standards of practice outlined here—using a sociocultural framework, exercising flexibility in one’s assigned role, and understanding and incorporating culturally specific strengths and protective factors into care—echo those employed in the NAMHS. These similarities highlight how accurate and meaningful data should be collected as well as how policy and programmatic efforts can and should be informed to reduce mental health burdens among adolescents.

Given the significance of economic instability as a driver of mental and physical health burdens among adolescents in LMICs, Ssewamala et al. report on the Suubi4her study, a cluster-randomized controlled trial conducted across 47 public secondary schools in central Uganda.³ Their findings provide evidence that conditional cash transfer can serve as a powerful economic empowerment tool for adolescents that can improve mental health outcomes.

NO HEALTH WITHOUT MENTAL HEALTH

Over the past decade, our global community has faced a growing number of shocks. As these challenges persist into the future, their impact on the mental health and well-being of adolescents cannot be ignored. Consistent and accurate measurement tools that allow researchers and advocates to understand the extent of mental health burdens as well as how social, political, and economic upheavals and climate crises drive these burdens is critical. With such information, we can continue the work of developing and testing interventions that disrupt the sociostructural drivers of poor mental health. As noted in the World Health Organization’s World Mental Health Report, to strengthen policies and improve prevention programs as well as access to mental health treatment that improve the mental health of adolescents, we need “all stakeholders to work together to deepen the value and commitment given to mental health, reshape the environments that influence mental health, and strengthen the systems that care for mental health” (https://bit.ly/3GNfZMD).