Even before the COVID-19 pandemic began, concerning mental health trends and major treatment gaps were noted among adolescents in the United States. According to data from the National Survey on Drug Use and Health, an estimated 13.3% of US adolescents aged 12-17 experienced at least 1 episode of major depressive disorder in 2017, yet 60.1% of these individuals did not receive treatment for their illness.
In addition, survey results from the Centers for Disease Control and Prevention demonstrated increasing rates of US high school students experiencing persistent sadness or hopelessness (from approximately 26% in 2009 to 37% in 2019), serious contemplation of suicide (from 14% to 19%),suicide planning (from 11% to 16%), and suicide attempts (from 6% to 9%). The highest risk levels were observed for White, female, and sexual minority students compared with non-White, male, and heterosexual students.2
Early findings indicate that these issues are being further exacerbated by the current crisis, with an especially high risk of worsening mental health among individuals with pre-existing psychological problems. These results have shown increased symptoms of depression, anxiety, and post-traumatic stress disorder among youth of various age groups.3,5 “The number, severity and duration of these symptoms are influenced by age, history of trauma, psychological status before the event, hours spent watching media coverage of the event, having a family member who died and the presence or absence of social and economic supports,” wrote Hertz and Barrios in a paper published in February 2021 in Injury Prevention.
They noted that school closures may reduce access to mental health screening and care for vulnerable students, considering the large number of adolescents — nearly 3.5 million in 2018 — receiving such services in educational settings.2 These settings represent the only source of mental health services for many adolescents, particularly those from low‐income households and racial and ethnic minority groups. The authors thus emphasized the heightened importance of collaboration between schools and community health professionals to address the growing mental health needs of students.
Adolescents and other youth are also affected by the impact of the pandemic on their caregivers, including unemployment, financial and emotional stress, and fear of infection, highlighting the need for adults to receive adequate care and support as well.6,7 Some youth have been forced to spend more time in abusive or otherwise dysfunctional homes due to quarantine requirements.
“Assessing the relative safety of a child at home is one of the major challenges posed to mental health professionals during a pandemic,” according to a November 2020 paper co-authored by Cécile Rousseau, MD, researcher, psychiatrist, and professor in the division of social and transcultural psychiatry at McGill University in Montreal, Canada.6 “Fueled by parental stress and in the absence of the benevolent gaze of the school or daycare, the risk of maltreatment is increasing as the rate of cases reported to youth protection is decreasing.”
Providers at hospitals across the US are reporting alarming increases in rates of attempted and completed suicides among youth — especially teenagers. One school district in Las Vegas has lost 19 children to suicide since the pandemic began. Regarding the increasing number of pediatric patients presenting to hospitals nationwide with suicidal ideation, clinicians have described them as having “worse mental states” compared to similar patients typically seen before the pandemic.8
Such trends underscore the vital importance of youth outreach and creative intervention and support during these times. Mental health providers “must continue to advocate to ensure that families and children get the mental health support that they need to support resilience, to decrease family conflict and child maltreatment, and to decrease risk-taking, unsafe, and dangerous behaviors.”
What are believed to be the reasons for the generally low rates of mental health treatment among adolescents even pre-pandemic? I believe there are 2 main reasons: First, MH services are overall difficult to access and often not very user-friendly for youth. Although some emerging models are addressing this, they are not generalized. Second, there is a widespread tendency to confound psychological distress and its expression — through sadness, anxiety, and anger — and mental disorder.
The first is associated with life being hurtful, which is very common, while the second is associated with more individual vulnerabilities. Of course, the 2 phenomena overlap, but in past times, distress was not medicalized or an object of treatment. Rather, it was addressed through interpersonal networks, spirituality, and so on. In the past decades there has been a shift in paradigm.
How has the pandemic affected and exacerbated mental health issues in this population?
The pandemic has generated first an acute stress response — which is normal, with fear and panic reactions, among others. To a certain extent, this has supported adherence to public health measures. As time passes, this becomes a chronic stress reaction with predominant avoidance symptoms such as denial and minimization of the pandemic risk. Frustration and anger regarding constraints have also increased, leading to scapegoating through conspiracy theories, and to legitimation of violence.
These are widespread reactions, which are not within the disorder range. For many people with vulnerabilities, however, the pandemic has exacerbated their symptoms, except for some cases of phobia — particularly school phobia — or cyberdependence, as these individuals may enjoy the confinement.
What are the relevant recommendations for clinicians about how to address these issues in practice and advocate for their adolescent patients?
Clinically, outreach to our patients to maintain continuity of care is crucial. In cases of frequent family conflict, virtual care should be used cautiously as it may not provide the needed confidentiality and safety and may aggravate the family conflict in some cases.
For new cases, management should include decreasing the impact of the collateral consequences of the pandemic — most commonly from social isolation and lack of stimulation — on adolescents’ development.
What are some of the broader, longer-term solutions that are also warranted?
Schools and colleges should be at the forefront of prevention. In Canada, pediatricians have advocated for the return of youth to school and the preservation of their social network (not partying, of course!). Youth need their peers to pursue their individuation-separation task, and this has been made impossible during confinement. We need to find a balance between the security of the elderly and the fulfillment of adolescent developmental needs.
Major depression. National Institute of Mental Health. Updated February 2019. Accessed online February 7, 2021. https://www.nimh.nih.gov/health/statistics/major-depression.shtml
Hertz MF, Barrios LC. Adolescent mental health, COVID-19, and the value of school-community partnerships. Inj Prev. 2021;27(1):85-86. doi:10.1136/injuryprev-2020-044050
Rogers AA, Ha T, Ockey S. Adolescents’ perceived socio-emotional impact of COVID-19 and implications for mental health: results from a U.S.-based mixed-methods study. J Adolesc Health. 2021;68(1):43-52. doi:10.1016/j.jadohealth.2020.09.039
Liang L, Ren H, Cao R, et al. The effect of COVID-19 on youth mental health. Psychiatr Q. 2020;91(3):841-852. doi:10.1007/s11126-020-09744-3
Ma Z, Zhao J, Li Y, et al. Mental health problems and correlates among 746 217 college students during the coronavirus disease 2019 outbreak in China. Epidemiol Psychiatr Sci. 2020;29:e181. doi:10.1017/S2045796020000931
Rousseau C, Miconi D. Protecting youth mental health during the COVID-19 pandemic: a challenging engagement and learning process. J Am Acad Child Adolesc Psychiatry. 2020;59(11):1203-1207. doi:10.1016/j.jaac.2020.08.007
Chatterjee R. Make space, listen, offer hope: How to help a suicidal teen or child. NPR. Published online February 2, 2021. Accessed online February 7, 2021. https://www.npr.org/sections/health-shots/2021/02/02/962185779/make-space-listen-offer-hope-how-to-help-a-child-at-risk-of-suicide
Chatterjee R. Child psychiatrists warn that the pandemic may be driving up kids’ suicide risk. NPR. Published online February 2, 2021. Accessed online February 7, 2021. https://www.npr.org/sections/health-shots/2021/02/02/962060105/child-psychiatrists-warn-that-the-pandemic-may-be-driving-up-kids-suicide-risk