Where next for youth mental health? Reflections on current research and considerations for the future

It is estimated that 50% of long-term mental health problems start by age 14 and 75% between 18 to 24 years (Department of Health, 2011; Kessler et al., 2005). The global cost of mental health disorders is estimated at US$16.1 trillion between 2010 – 2030 (Bloom et al., 2011) and the human costs are greater still. Suicide takes the lives of nearly 800,000 per year (World Health Organization, 2019), depression is set to be the leading cause of disease burden globally by 2030 (Malhi & Mann, 2018), and people with serious mental health conditions die an average of 10 – 20 years younger than the general population (Chesney et al., 2014). Managing the cultural, economic and environmental challenges and uncertainties that lie ahead will require the direction of a resilient, unified and skilled set of individuals and communities. By intervening early with evidence-based universal or targeted programs and fit-for-purpose youth mental health services, we have the potential to strengthen the mental health of our children and young people (Dodge, 2020; Malla et al., 2016) and reduce the number of young people who go on to having mental health problems in adulthood.

A report by the UK Education Policy Institute (2020) highlighted the rising demand for specialist child and adolescent mental health support (CAMHS) services, yet one in four referrals are rejected and there is great regional variation across England. For those accepted for treatment there are long waiting times of up to 6 months (Crenna-Jennings & Hutchinson, 2020). It is hardly a surprise that many children reach crisis point, with emergency admissions for young people with mental health problems increasing in the last 10 years (Frith, 2016). This is a trend also seen in North America (Chun et al., 2015). Across the European Union (EU), with a mix of healthcare models, there are similar variations across regions: 30% of countries do not have a national policy for child and adolescent mental health, and there is heterogeneity in resource allocation which does not match need (Signorini et al., 2017). Rates of youth mental health disorders vary across the EU (Husky et al., 2018), as do self-reported accounts for self-harm (17.1% in Hungary to 38.6% in France; Brunner et al., 2014) and lifetime suicide attempts (4.1% in Armenia to 23.5% in Hungary; Kokkevi et al., 2012). Taking a more global perspective, prevalence from a worldwide-pooled meta-analysis estimates that 13.4% of under 18 s have a mental disorder (Polanczyk et al., 2015), and in 21 low- to high-income countries, 20.3% of college students met criteria for a mental health disorder (Auerbach et al., 2016).

The global prevalence of youth mental health problems is still much of a mystery as it is limited by different research priorities, research capacity, levels of research funding, different classifications of disease and underreporting of prevalence (Collishaw, 2015; Wainberg et al., 2017). Research into the epidemiology and treatment of mental health disorders is more sparse in low- and middle-income countries (LMIC) than high-income countries (HIC) such as the United States, Canada, Australia, New Zealand, the UK, and certain countries in northern and western Europe (Erskine et al., 2017; McKinnon et al., 2016). This is despite 85% of children living in LMICs. Prevalence data for youth mental health conditions has ranged from 4.52% in LMICs to 26.41% in HICs (Erskine et al., 2017).

This journal has previously reported on the topic of student mental health in a special edition for 2018. In this month’s editorial, we have cast a wider net, considering youth mental health, a term encompassing early years to early adulthood, from across the world, to understand the current state of research, promising new developments and discuss the future of research in this area.

Prevalence and causes: the what, why and how?

“We need to understand the causes to inform prevention” (Gunnell et al., 2018).

The nature vs. nurture debate on the determinants of mental illness continues (Uher & Zwicker, 2017). For university students, there are some clear risk factors, but also some protective strategies emerging from the literature. Predictors of mental distress include cyber-aggression (Mishna et al., 2018), loneliness and assessment stress (McIntyre et al., 2018), alcohol and drug misuse, financial distress, lack of enjoyment with the academic course, conflict with friends (Dachew et al., 2019). The content of a student’s worries and anxieties may vary depending on their year of study (Macaskill, 2018) and it can be challenging to uncover whether academic dissatisfaction is the cause of their mental health problems, or whether it is an effect (Lipson & Eisenberg, 2018). However, a university education may also be a protective factor. For example, in a US study by Hardy et al. (2018), educational engagement was found to be associated with a shorter duration of untreated psychosis for college-age populations. A common theme throughout all these studies was the importance of social connectedness and its protective mechanism against loneliness and mental distress. Social support should not replace other therapeutic interventions (Tran, 2018) but opportunities to establish strong social bonds may particularly benefit first year students adjusting to university life (Knoesen & Naudé, 2018). However, the capacity for building connections in early adulthood also depends on individual factors, many of which are influenced by childhood and the surrounding environment, including poverty and other socioeconomic inequalities (Reiss, 2013; Roberts et al., 2016). Physical abuse and emotional neglect is predictive of many mental health disorders (Salokangas et al., 2019) and positive family dynamics seems related to satisfaction with mental health, a sense of meaning and purpose, social misfit status and academic performance (Craig et al., 2019). Maximising the potential for positive familial relationships and supporting vulnerable youth therefore requires a multi-agency, whole society approach, with research collaborations across sectors.

Testing treatments

Many different interventions have been attempted for student mental health: from canine therapy (Binfet et al., 2018; Wood et al., 2018), to structured peer support (Byrom, 2018). Research into such innovative interventions are welcomed and incorporating the service user voice throughout is an essential part of this research process (Callard et al., 2012), helping us to better understand the needs and preferences of the younger generation. For instance we know that young people’s attitudes towards traditional face-to-face psychological therapy and pharmaceutical interventions can be varied and complex (Holding et al., 2019). Service accessibility (e.g., appointment times to fit around education), feeling listened to, and structured sessions that feel “useful” (Persson et al., 2017) are also vital. These all come from incorporating the user voice and further qualitative studies are needed especially across different cultural settings. This would greatly benefit our understanding of what is acceptable and feasible for this generation. Teachers also need training in the skills to provide any emotional support, as many do not feel equipped to deal with youth mental health problems (Gulliver et al., 2018). At an institutional level, universities may wish to consider introducing services and courses that increase self-efficacy and motivation in students with mental health problems, encouraging all faculty members to display a more regular, active interest in their students’ progress (Lipson & Eisenberg, 2018). Finally, to ensure the most cost-effective, efficacious treatments are commissioned, funders will be keen to see further research into the fair financing of services (e.g., case-mix classification, see Martin et al., 2017) and how best to measure clinical outcomes for monitoring treatment response.

Looking ahead: future directions for youth mental health research

Prevention and early intervention may be popular buzzwords in mental health but the potential benefits are emerging (Chua et al. 2020; Correll et al., 2018; Malla et al., 2016; Werner-Seidler et al., 2017). By creating youth-focused, integrated services and adopting a whole-school, whole-community, approach to mental health that equips young people with the tools and resources to manage their mental health, the mental health of populations worldwide can only improve (Glazzard, 2019; McGorry & Mei, 2018). An evidence base of universal interventions in the classroom is developing (O’Connor et al., 2018), as is our understanding of which skills may enhance psychological well-being. For example, positive mental health is predicted to increase if young people can develop positive psychological strengths, such as hope, efficacy and optimism (Selvaraj & Bhat, 2018), and the capacity for self-compassion has positive implications for help-seeking behaviours (Dschaak et al., 2019), as well as mental health and connectedness to others (Neff & McGehee, 2010). Mental health literacy is also important for reducing stigmatising and misinformed views among the public and professionals alike, and integrating lessons about mental health as part of a university degree has showed great promise (Pingani et al., 2020). Finally, teaching practical life skills in adolescence (e.g., managing independence, building new social networks, protecting oneself against crime) are low-cost strategies that may help adjust to adult life post-secondary education, enabling them to “flourish” (Knoesen & Naudé, 2018).

Whatever the intervention, researchers can gain a lot from actively seeking out the youth voice and understanding their lived experience: from qualitative interviews that explore topics such as the clinical or educational experience in greater depth (Holding et al., 2019; Macaskill, 2018), to novels and books narrating the realities of mental distress (McIntosh, 2020; Rawcliffe, 2020). Young people should be supported in moving from “characters” in research to “authors” who are actively involved in shaping research questions, study design, its delivery and impact (MacSweeney et al., 2019). Notably, when drawing conclusions from the data, it remains important to keep in mind individual variation in treatment preference, and the vast heterogeneity which may exist within populations of similar age groups. Any such research collaborations, and youth mental health services or programs more generally, should be actively promoted in local communities to increase awareness, as a step towards normalising mental health in the community, reducing stigma, and reducing barriers to help-seeking behaviours (Perera et al., 2019). At the National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) in London, our strategy for service user and carer involvement is anything but tokenistic (NIHR Maudsley BRC, 2020). We have several advisory groups, including one for 16 – 25 year olds, and each member is encouraged to participate across the research cycle: from shaping research design, to overseeing projects and dissemination of findings. By drawing on insight from lived experience, and commenting on the lay-friendliness of documents, researchers can truly benefit from research co-production.

Looking at a macro level, although there is some promising research coming from LMICs (Amare & Getinet, 2019; Dachew et al., 2019), we need to support the development of research from these countries to continue, taking into account rapid social changes (Collishaw, 2015). Such studies, as well as cross-cultural studies within populations, can only help develop the knowledge base for how best to accommodate the needs and experiences of culturally diverse youth populations, promoting “culturally attuned healthcare services” (Afolabi et al., 2017). In designing any intervention, researchers should consider carefully the methodological choices they make and its suitability for the research question, as this supports comparability across settings (Collishaw, 2015; Fabiano et al., 2014).

Ultimately, there is no one-size-fits-all solution to tackling the mental health crisis, but continuing innovative research into the mental health of young people, from all walks of life, is a good place to start.

Disclosure statement

No potential conflict of interest was reported by the author(s).