Youth & mental health: Challenges ahead

Our world is home to 1.8 billion young people of age 10-24 yr, contributing about one-fourth of the total world population. Nine out of 10 of them live in the less developed countries. India has the world's highest number of this age group with 356 million, despite having a smaller population than China. Of all the population groups, the young population is growing fastest, especially in the poorest nations1. The young age is one of the most important phases of life, being the formative period with major impacts on the future. The phase carries special significance for mental health, since most mental and substance use disorders (MSUDs) have onset in young age or adolescence, and many tend to run a chronic or relapsing course2. A world changing at a fast pace carries special significance here, since it further poses a challenge to mental health, especially for the young who are in a formative stage of life3. In this background, the theme of the world mental health day this year ‘young people and mental health in a changing world’ is appropriate.

Changing world & mental health

To be in optimal mental health is essential for optimal functioning as well as for productivity for any person. In the last few decades, the world has been changing very fast, especially with the invention of faster modes of transport, ease of migration across countries and the revolutionary developments in information technology (IT). This has brought major challenges to the mental health professionals. The IT revolution has been accompanied by ill effects such as reduced social interaction, physical activities and intimacy and a more sedentary lifestyle1. Real life in-person interaction is being increasingly replaced by an artificial sense of intimacy through the social networking platforms. The current day youth spends a substantial time of the day on the internet and is exposed to information implosion including cybercrimes, cyberbullying and violent video games. The internet is also a source of (mis)information, source of which is often not verified and has a potential of harming the young mind. Blue Whale game is a recent example of such a harm4,5. Increasing violence in the young people is another important issue needing attention since youth are at risk of being victims as well as perpetrators of violence3. Cyberbullying is another mode of bullying, which has become increasingly common in the last few years with the increased access to and use of the internet-based services. Behavioural addictions and cyberbullying are two important harmful effects of the modern digital age, which especially affect the young4. Internet use disorder is now being recognized as a new disorder needing therapeutic interventions6. Street children and those living in shelter homes are another important group of young people, which is especially vulnerable in the absence of family support and a stable home. This group is frequently exposed to harms due to drug use, physical and sexual abuse, criminal behaviour and violence7. Mental ill-health, substance use and violence in the young population are some important challenges faced by the mental health professionals as well as the society.

Extent of problem

About 20-25 per cent of the young people suffer from MSUDs worldwide7. Recently concluded National Mental Health Survey of India8 estimates the current prevalence of mental disorders in the age group of 18-29 yr at 7.39 per cent (excluding tobacco use disorder) and lifetime prevalence at 9.54 per cent. The prevalence of mental disorders (excluding SUDs) in the age group of 13-17 yr is reported to be 7.3 per cent. The young people also suffer a high rate of self-harm, with suicide being a leading cause of death9. About half of the all mental illnesses are known to begin by the age of 14 and three-quarters by mid-20s2. Since the MSUDs tend to have a chronic relapsing course, taking care of the mental health of the young people becomes a priority.

Globally, MSUDs are recognized as the leading cause of all non-fatal burden of disease and years lived with disability10. Among various age groups, adolescents and young adults (10-29 yr) probably suffer the most, contributing to the highest proportion of disability-adjusted life years among various age groups11. The burden associated with common mental disorders (depressive and anxiety disorders) rises abruptly in childhood (1-10 yr) and peaks in adolescence and early to middle age (10-29 yr). The burden associated with less common but chronic disorders, such as schizophrenia and bipolar disorder, although higher in early adulthood (peaking between 25 and 50 yr of age), also impacts the childhood and adolescence. The burden from illicit substance use is highest among young adults (ages 15-29 yr), but for alcohol the largest burden is observed in the age group of 25-50 years. If untreated, these conditions severely influence children's development, their educational attainments and potential to live fulfilling and productive lives1,3. The young persons with MSUDs, like their adult counterparts, face the challenges of stigma, isolation and discrimination and also lack of access to health care and education facilities. There is huge treatment gap ranging from 73.6 per cent for severe mental disorders and 85.0 per cent for common mental disorders to 91.1 per cent for substance use disorders8.

Need to have a well-planned strategy

A public health approach is needed that is focused on both controlling the risk factors as well as enhancing protective factors. Common risk factors for MSUDs include poverty, malnutrition, child abuse, mental illness in parents, family conflict, death of a family member, bullying, poor discipline in the family, academic failure and exposure to violence. Educational pressures, constantly reinforced by the family and the society, have been seen in the background of many suicides in young people in India9. Consistent and engaging parental style, being in fulltime education, zero tolerance for bullying at school, involvement in community activities, religious observance, low levels of conflict in the family and social support have been recognized as the protective factors against MSUDs3.

There are a number of barriers to taking care of the mental health needs of the youth including lack of services, lack of awareness, myths, misconceptions and stigma and low priority to mental health3. Early identification and intervention for the problems remain vital to the solution. Raising community awareness about early signs of MSUDs, need for their treatment, dispelling the associated myths and misconceptions, and providing easily accessible and affordable treatment facilities are crucial3,7. Schools and colleges, in particular, offer a unique setting for mental health promotion in young people. Any strategy aimed at improving the mental health of the youth needs to aim at bridging the knowledge and service gaps and should include school-targeted programmes and community-based services12. Targeting educational institutions for raising mental health literacy both among students and teachers for early identification of depression and other mental health issues, substance use disorders, conduct issues, cyberbullying and suicidal risk is a crucial step in this direction. A study on suicide prevention programme in 168 schools covering 11,110 adolescents with a median age of 15 yr, found equipping the students with mental health awareness (Youth Aware of Mental Health Programme) to be more effective at reducing suicide attempts and severe suicidal ideation than a gatekeeper training for teachers and screening by professionals13. Strategies such as enhancing social skills, problem-solving skills and self-confidence of the young population can help prevent mental health problems such as conduct disorders, anxiety, depression and eating disorders as well as other risk behaviours including those that relate to sexual behaviour, substance abuse and violent behaviour.

Integration of mental health in general medical, paediatric and primary care can be an effective strategy since this facilitates contact with the target population. This approach is likely to work since most of the common mental health issues may not require a specialist care and can be handled by professionals from various health cadres. The integration of mental health services with other youth health and welfare services can also be an effective method of dealing with mental health problems in youth3,7. Health workers need to have the competencies to relate to young people, to detect mental health problems early and to provide evidence-based treatment. The general practitioners and other primary health care workers need to be educated to engage young people, recognize MSUDs and deliver simple and effective treatments including supportive counselling, cognitive behaviour therapy, and where appropriate, psychotropic drugs. Specialized and multidisciplinary care is required for youth with multiple or complex needs. There is also a need to establish dedicated services to address the emerging issues like behavioural addictions among youth4. The emphasis needs to be on reducing risk factors and strengthening protective factors, which are common to several risk behaviours, such as substance abuse, self-harm and sexual risk behaviours.

Ironically, health spending is lowest in countries with the highest youth proportions1. It is important to mention here that as a result of a well-planned programme for HIV and AIDS, an equally stigmatizing illness such as mental disorders, new HIV infections in India have decreased by 46 per cent and AIDS-related deaths have decreased by 22 per cent since 2010. In 2016, India had 80,000 new HIV infections compared to 150,000 in 2005, and 62,000 AIDS-related deaths compared to 150,000 in 200514. Taking an example of fall in new incident cases of HIV and reduction in deaths due to AIDS, community awareness on mental health with special focus on schools and other educational institutions along with sustained efforts at service development, and better budget allocation for mental health, it should be possible to meet the challenges of mental health in youth in low- and middle-income countries.