Based on an article by Matt Schur from the AMT Pulse.
In 2021, at the height of the pandemic, U.S. Surgeon General Vivek Murthy released a statement about “the defining public health crisis of our time.” He wasn’t referring to COVID-19, then still raging across the country; rather, he was talking about the mental health crisis plaguing young people. The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association shared his concerns, putting out a joint statement saying that there is “a national emergency” for youth mental health.
While these struggles cut across all backgrounds, researchers are finding that minority groups, people who identify as LGBTQ+ and girls are especially affected. According to the Centers for Disease Control and Prevention (CDC), 13% of U.S. high school girls had attempted suicide in 2021; 30% seriously considered suicide. Consider, for a second, that the average number of students in a U.S. high school is 555. If you were to take that average high school and assume girls make up half the population, that would mean roughly 36 girls in that high school alone attempted suicide within the last year. Nearly 84 girls in that school would have seriously considered suicide.
In the CDC’s 30 years of collecting data on mental health trends among younger populations, “We’ve never seen [these kinds] of devastating, consistent findings,” said Kathleen Ethier, director of CDC’s adolescent and school health division, in a press release about the organization’s research. “There’s no question young people are telling us they are in crisis. The data really call on us to act.”
Emily Pluhar, PhD, Pediatric Psychologist, Boston Children’s Hospital, says data shows emergency rooms (ERs) are overwhelmed with young teens who are experiencing safety issues and a threat to themselves. “ERs are constantly trying to keep up with the demand. There are often teens boarding in ERs for prolonged periods because there aren’t enough mental health resources to meet their needs,” says Pluhar, who is also an Associate Professor at Harvard Medical School’s Division of Adolescent Medicine. “In certain instances, mental health patients are admitted on medical floors since there aren’t enough inpatient psychiatric beds, and those floors aren’t equipped to provide mental healthcare beyond safety monitoring. As providers, we’re trying to keep up with the needs of our teens with limited resources.”
A Shift
Decades ago, alcohol and drug use, drunk driving, teen pregnancy and cigarettes were the biggest threats to young people. Now it’s mental health. The shift happened quickly— until 2008, rates of depression and suicide were declining. Healthcare researchers are still trying to pinpoint what exactly changed. For some in the medical community, it’s hard not to draw connections that two major social media companies launched to the public in 2006: Facebook and Twitter. Then, in 2007, Apple released the first iPhone.
The average teen today spends 4.8 hours a day using social media, according to Gallup. Children and adolescents who spend more than three hours a day on social media have double the risk of mental health problems, according to the U.S. Department of Health and Human Services.
“The social media apps popular among youth seem heavily engineered to be like slot machines,” says Nicholas Carson, MD, Division Chief, Child and Adolescent Psychiatry, Cambridge Health Alliance; Research Scientist, Health Equity Research Lab; and Assistant Professor in Psychiatry, Harvard Medical School. “They’re very good at getting people to spend more time on screen.” However, the direct link between social media use and poor mental health has been inconclusive. For as many young people whose negative experiences and thoughts are intensified online, there are many others who have found vital connections and positive engagement. Researchers suggest that the impact of screen time and social media use might be more indirect, acting as a contributor to the mental health crisis—not the cause.
For instance, the barrage of information on social media is exposing teens to unprecedented stressors, says Bonnie Nagel, PhD. At the Oregon Health & Science University (OHSU), she is the Senior Associate Vice President for Research, a Professor of Psychiatry and Behavioral Neuroscience, and a Vice Chair for Research in Psychiatry. “Social media and the internet give us access to so much more exposure to stressors, including natural disasters, climate change, huge political polarization and structural racism,” says Nagel, who is also the Director of the Center for Mental Health Innovation at OHSU. “There’s so much access to media for teens, which is challenging because their brains aren’t equipped to manage these sensitive and bigger adult issues,” Pluhar says. “Plenty of kids are deeply impacted by these exposures, and it’s constant for them.”
Nagel also points out that social media can replace time spent in person with friends and family. “While we feel like we’re connected through social media, I would argue that it’s taking the place of meaningful social connectedness,” Nagel says. “Part of the reason we saw escalating rates of depression during the pandemic was because of that lack of real social connectedness.”
Loneliness is strongly linked to anxiety, depression and suicide. “We must prioritize building social connection the same way we have prioritized other critical public health issues such as tobacco, obesity and substance use disorders,” Surgeon General Murthy said.
Social media and phone access are also disrupting sleep, which is crucial to a developing brain. “Oftentimes, kids are forgoing sleep because of gaming, social media, YouTube, Netflix and more,” Carson says. “They’re just refreshing constantly.”
Beyond the Phone
Many factors beyond social media and phone use are contributing to the crisis. COVID-19 presented many challenges, everything from deaths to isolation to many parents losing jobs. Ironically, though efforts to destigmatize mental health are crucial, the effects on youth are somewhat mixed, Nagel says.
“Talking about mental health problems is more common than it used to be, which, in many ways, is a good thing,” Nagel says. But that spotlight has also meant that kids are thinking about and getting exposed to health concepts more than ever. Lucy Foulkes, an Oxford psychologist, labeled this phenomenon as “prevalence inflation” in an interview with the New York Times, where greater awareness of mental illness can lead kids to talk about normal life struggles in terms of “symptoms” and “diagnoses.”
Nagel highlights a recent shift, especially among young people, of having a low tolerance for unpleasant feelings or what she calls “distress intolerance.” “When we think about reducing risk for depression and suicide, it’s important to have the ability to feel stress and sadness while also being OK,” Nagel says. “Societally, when someone is sad or angry, we so often quickly think, what can we do to make those feelings go away? But it’s normal to feel sadness, anger and stress. As a society, we’ve over-pathologized negative emotions and said, ‘Let’s make these feelings go away as quickly as possible.’ While we don’t want people to experience persistent negative emotions, part of the goal should be to be able to feel those things and figure out how to also be OK. That is critical. But it’s something, partly because of parenting styles, that we’ve diminished in society. Distress tolerance is an important predictor of mental health outcomes.”
Most at Risk
Fifty-seven percent of U.S. girls reported persistent sadness and hopelessness in 2021, up from 35% in 2011. While rates for boys are up, they’re experiencing depression and suicide attempts at significantly lower rates.
Much like the crisis itself, the reasons why girls are in such distress are multilayered. Rape and sexual violence are on the rise, with 20% of girls reporting such an experience in the previous year. The age of puberty is also declining, a trend that is confounding researchers. Across dozens of countries, the age of puberty for girls has dropped about three months per decade since the 1970s.
“Research shows that earlier onset of puberty is associated with mental health sequelae such as depression, low self-esteem, physical insecurities resulting in eating disorders, bullying, earlier exposure to sexualized behaviors and substance abuse,” Pluhar says. “Rapid brain development occurs during puberty, including complex emotions and a lot more understanding about identity development, social comparisons and needing validation from peer groups. They don’t have the tools to manage the challenge of processing complex feelings that early.”
Social determinants of health are also contributing to outcomes, especially across minority communities. For instance, Black kids aged 10-19 have experienced the largest surge in suicide rates, increasing 78% since the start of 2000. The suicide rate for Alaskan Native and American Indian youth is 2.5 times the national average, marking the highest rate across all ethnic and racial groups, according to the CDC.
“Depression among Black youth has not been effectively identified, is often misdiagnosed and frequently left untreated, leaving many to suffer,” Pluhar says. This happens because of multiple barriers, such as varying presentations of depression in Black youth, minorities not being represented in mental health providers, cultural stigma against seeking help, financial resources, access to care and more, Pluhar says.
Carson points out that there has been a recent push for more inclusive research in the suicide field to understand the impact of racism, discrimination and the lack of access to care. “Many Black youth have a challenging time navigating a system that just isn’t understanding of their particular experiences of hardship, exclusion and discrimination,” he says.
Stepping In
Funding is a major priority, with many kids lacking access to care. “There’s been a big need for more mental health treatment capacity in the system: more inpatient beds, outpatient therapists, outpatient psychiatrists and all the intermediate levels of care between inpatient and outpatient, like partial programs and partial hospitals,” Carson says.
Carson also says that schools, frequently acting as the country’s de facto mental health system, need more funding and resources to address mental health. “We have to think about the role of school districts being staffed appropriately with programs for screening or intervention, adjustment counselors, and providing support to teachers and parents to recognize when students are distressed and then teaching them what to do.”
Identifying risk early is important, Nagel says. “For many mental health problems, we know what the risk factors are, so we should try to identify youth who might be at risk for developing problems before they start. Brief interventions to promote healthy behaviors, normalizing feeling a variety of emotions and breeding distress tolerance will be helpful.”
Tackling the social media landscape won’t be easy, Carson says, but he’s been encouraged by the work of people like Tristan Harris and the Center for Humane Technology, which is, in part, “urging the industry to be more thoughtful about adolescent brain development and how vulnerable kids are to not controlling their screen time and to the content that is delivered to them by algorithms that seem designed to push increasingly more negative and sensational content.”
While scaling up these various services and building the labor force to oversee these efforts will take time, healthcare workers are uniquely positioned to make an immediate impact. “I think as a medical community that interacts with young people, the best thing we can do is be empathic, warm, connected humans,” Nagel says. “Every time you touch another person’s life, you’re facilitating social connectedness, so whether you’re a phlebotomist or a medical assistant or whoever you are, every time you touch a person’s life, you have an opportunity to have a positive impact through connection.”
Suicide Vs. Self-harm
One distinction that Emily Pluhar says is important for people, especially healthcare professionals, to understand is the difference between suicide and self-harm, which can often be conflated. “What is important to remember is that there is a relationship between the two, but they are two unique behaviors. It is crucial to define the function of the behavior to understand the differences.
The function of non-suicidal self-injury is to regulate emotion. It’s a maladaptive coping skill that we know is very reinforcing because it does temporarily help teens re-regulate, so that increases the likelihood of doing it again.” The function of suicide, Pluhar says, is to end suffering. “The relationship between the two is linked closely. The higher the frequency, intensity and duration of self harm, the greater the likelihood of suicide attempts,” she says. “Rates of both are increasing exponentially, and we’re seeing a lot of parents and schools at a loss with how to manage self-harm and suicide, in addition to not knowing how to manage the contagion effects of all of it as well.”
Additional resources:
AMT has several mental health continuing education resources on topics of burnout, coping with workplace stress, understanding and treating PTSD, and reducing violence and suicide in mental health. Check out our available courses here.