Adolescent Mental Health: The Troubling Picture

Adolescence is a crucial period that marks the transition from childhood to adulthood. It is a time period characterized by biopsychosocial alterations (altered hormones and a changing body), social and environmental changes, and changes in the brain. Commonly, the period between the ages of 12 and 18 years is considered adolescence, and this roughly coincides with the onset of puberty. An assemblage of changes occurs during adolescence, including an increase in adrenal and gonadal hormones, an increase in risk-taking behaviors, changes in emotional reactivity, changes in the social and school environment, and an increased sense of autonomy. No wonder it is a time when there is a greater vulnerability to mental health problems.^[1] Most mental health problems arise during adolescence, and this stands to become a major public health challenge soon. The deteriorating trends of mental health among adolescents globally are alarming. The World Health Organization mentions that globally, one out of seven individuals between the ages of 10 and 19 years experiences mental illness.^[2] Mental illnesses in adolescence can contribute to long-term morbidity. It is projected that depression will be the leading cause of disability-adjusted life years in 2030.^[3]

A study analyzing data from the Global Burden of Disease Study of 2019 revealed that of 2516 million individuals aged between 5 and 24 years, 293 million had at least 1 mental disorder, and 31 million had substance use disorders globally. The prevalence of mental disorders in the age groups of 10 to 14 years and 15 to 19 years was as high as 12.40% and 13.96%, respectively.^[4] This accounts for one-fifth of all mental disease-related disabilities (due to all causes) in the age group of 5-24 years. Furthermore, the World Economic Forum in 2011 found that mental illnesses were one of the leading causes of loss of gross domestic product (GDP) globally. Subsequently, the global cost of mental illness is expected to rise to more than double from 2010 to 2030.^[5] The COVID-19 pandemic has painted a gloomier picture in its aftermath. Children and adolescents were found to be more vulnerable to mental illness due to the dynamic interplay of individual, familial, social, and peer-related factors.^[6] More astonishing is that suicide has emerged as the prime cause of death among people aged between 15 and 24 years in Australia, in those aged 15-19 years in New Zealand, and in India among people aged between 15 and 39 years.^[7-9] These are compelling pieces of evidence that are suggestive of the dwindling mental health of the youth and future generations. Such figures quintessentially draw us into understanding adolescents and what makes them so vulnerable. Not focusing on the mental health of adolescents and the youth now is projected to cost the global economy an estimated 16 trillion USD between 2011 and 2030.^[10]

Focusing on adolescent mental health now is imperative. To see palpable progress in adolescent mental health, understanding the factors that are contributing to the current downhill trend needs to be a priority. Adolescence is influenced by a complex network of family, school, peers, community, social media, and other cultural influences. Family relationships change as adolescents press for greater autonomy. With a better global economy, family patterns have shifted to nuclear families, implying more investment by the parents into the child’s education and welfare and better stability.^[11] However, this drift has not been uniform across the globe. In high-income countries, divorce and remarriage of parents, and changes in cohabitation of parents, can be a common situation that adolescents go through. In North America and Europe, around a fifth of all adolescents live in single-parent households.^[12] Single-parent families can lead to an increase in poverty and a decrease in education for adolescents.^[13] Unstable family environments have been linked with poor outcomes for adolescents, such as teenage parenthood, early marriage, and unstable marriages in their later lives.^[14] Exposure to family violence during adolescence is more likely to lead to school drop-out in adolescence with poor academic performance, substance abuse, and engagement in abusive relationships in adulthood.^[15] Additionally, parenting styles and the quality of parent-child relationships are also known to be linked to adolescent well-being.

If one were to unpack the factors related to poor mental health, social media use would be the most frequently mentioned among adolescents. The past decade has seen a dramatic increase in the use of social media and the internet, irrespective of socioeconomic status. A study found that social media use and mental health are negatively associated, and the use of social networking sites was negatively related to self-esteem.^[16] However, evidence shows that there is more to it than meets the eye. A complex and bidirectional relationship exists between social media and mental health. Consumption of social media could potentially affect how the brain develops in adolescence and add to mental health difficulties and life satisfaction.^[17,18] Internet use also exposes adolescents to hazards like cyberbullying, loneliness, and poor sleep. Nonetheless, the limited current evidence paves the way for further research.

With time, adolescents now face extreme competition in examinations, university admissions, and jobs. Lately, studies have noted a surge in school-related stress and burnout among adolescents.^[19] This has been particularly more pronounced in adolescent girls who presented with psychosomatic symptoms and has created a greater gender gap for poor psychosomatic health. Societal pressure is also hypothesized to play a role in adolescent mental health, especially for girls.^[20] This, however, varied across countries. A study found that between 2022-2014, countries with a higher GDP and more educated citizens showed more robust associations between school stress and mental health problems.^[21] Since higher education levels meant lower adolescent mortality in both sexes and greater wellbeing in adolescences and adulthood, this conflicting revelation of school stress necessitates embracing school-level policy changes that promote school belongingness and mental wellbeing.

Lifestyle changes have been the most prominent over the years. The food today is mostly processed and high in fat and sugar content, with the advent of quick service restaurants and packaged foods. These mostly appeal to the younger clientele of the society, especially among the higher socioeconomic strata, and hence are a problem that may not be evenly distributed globally. Evidence has established that high-sugar, high-fat diets can alter proteins necessary for brain development.^[22] Processed foods have also been linked to inflammatory markers. Cross-sectional associations have been found between unhealthy dietary patterns and poor mental health among adolescents. Future research into the global food environment and mental health could raise the possibility of dietary interventions for the prevention of mental illness.^[23]

All of these factors, however, are known to vary across nations. Low- and middle-income countries and other low-resource settings may experience certain factors disproportionately. Poverty and the growing inequalities between the rich and the poor, even in high-income countries, have been known to be a significant risk factor for poor mental health. Socioeconomic disadvantage meant low access to education, deprived living conditions, child marriages, exposure to violence, and poor to no support for growing adolescents, which are troublesome for mental wellbeing.^[24] Collectively, growing socioeconomic inequality, geopolitical insecurity, unregulated social media and declining social interconnectedness, and climate change have come to be a recipe for disaster for the future generation. On top, the stigma related to mental illness further leads to negligence of mental health needs.^[25,26]

Most countries have escalated their mental health programs to create awareness and eliminate the stigma. The World Health Organization (WHO) has developed multipronged approaches targeting adolescent mental health-such as the Helping Adolescents Thrive (HAT) initiative with UNICEF. WHO also has a module on adolescent mental health and behavioral disorders as part of the mhGAP intervention guide 2.0. LIVE LIFE is an implementation guide by the WHO for countries to help strengthen policies and efforts towards suicide prevention.

India has also taken a turn for the better with the National Mental Health Programme, which functions at the district level as the District Mental Health Programme and delivers mental healthcare at the primary care level. The Rashtriya Kishor Swasthya Karyakram (RKSK) of India is a community-based approach aimed at adolescent health, which also includes mental wellbeing in its gambit.^[27] More recently, the Supreme Court of India appointed a National Task Force to address mental health and the growing number of student suicides in higher educational institutions. It is a welcome move for the future generation. However, a lack of careful implementation, with trained mental health and allied professionals, can be an empty promise of a better future for the adolescent population. An important lesson to learn here is that for our youth to be mentally healthy and take over the reins; adolescent mental wellbeing necessitates priority. Longitudinal research into the mental health of adolescents could be revelatory of causal association for declining mental health. Mental healthcare for adolescents should be holistic and optimistic, aimed at early intervention and prevention. It should be affordable and easy to access. It should offer evidence-based care, tailored to the stage of illness, and be guided by shared decision-making.^[28]

*The authors recommend reading The Lancet Psychiatry Commission on Youth Mental Health for further insights on the topic.