Viewpoint
June 21, 2023
Addressing the Mental Health Crisis in Youth—Sick Individuals or Sick Societies?
Awais Aftab, MD1; Benjamin G. Druss, MD, MPH2
Author Affiliations Article Information
JAMA Psychiatry. 2023;80(9):863-864. doi:10.1001/jamapsychiatry.2023.1298
The prevalence of anxiety and depression has been increasing in the US as well as in many other parts of the world. This trend, beginning in the 2010s, has largely been concentrated among adolescents and youth.1 At least 2 broad sets of characterizations have been proposed in the scientific literature and lay press, the first viewing this increase as an epidemic of psychiatric disorders2 while the other seeing the increase in psychological distress in youth as reflective of sociopolitical adversity and disorganization.3 At the risk of oversimplification, this contrast may be viewed as a sick individuals vs sick society polarity. Such explanatory dualities present clinicians with the challenge of how to navigate concerns about excessive medicalization and address complex social determinants of health in clinical settings. Moving past conceptual binary constructs fueling this polarization can be an important first step in addressing the mental health crisis in youth. Herein, we discuss the reasons for this polarization, strategies to overcome it, and how these insights should inform clinical practice.
Teenagers and young adults face many challenges that affect them disproportionately. The growth of social media has made the adolescent dynamics of identity development even more turbulent and has subjected teenagers to peer pressure and online harassment. Economic challenges have left many young adults with bleak prospects of employment and house ownership, and youth face anxiety about climate change and its potentially devastating consequences on their future lives. There are also cohort effects in how individuals born between 1980 and 1995 (Millennial generation) and those born between 1996 and 2010 (Generation Z) express mental distress; many youth use psychiatric terminology in their everyday lives and social media posts. These realities could lead to the conclusion that clinical interventions have a limited role to play in addressing problems that are primarily consequences of a sick society.
The general awareness that the mental health crisis in youth is intertwined with sociopolitical turmoil has blurred the boundaries between social and medical perspectives. However, clinical care largely remains focused on individual interventions with an implicit biomedical outlook focused on treating sick individuals. For instance, in 2022, the US Preventive Services Task Force recommended screening for anxiety in children and adolescents aged 8 to 18 years, but the report mentioned only psychotherapy, pharmacotherapy, and collaborative care as treatment options.4 This discrepancy points toward a growing need to change how clinicians think about the care of young people in distress, including a better understanding of how social factors may contribute to patients’ clinical presentations.
Ultimately, binary distinctions between disordered vs normal distress in the face of stressors, biological vs psychosocial etiologies, and individual treatment vs public health approaches boil down to a constricted and overly narrow view of the medical model. Concerns about medicalization of the psychological lives of youth are triggered by legitimate fears: critics are worried that by conceptualizing distressing responses in psychopathological terms, the relationship to context will be lost or minimized, self-understanding of individuals will be adversely changed, and sociopolitical activism will be replaced by individual medical treatment. Remedying these concerns requires actively emphasizing medical, public health, and policy approaches that take context, self-understanding, and political action seriously.
It has been argued that estimates of psychopathology based on symptom ratings and epidemiological questionnaires inflate the prevalence of mental disorders.5 There are good reasons not to accept elevated symptomatology as sufficient evidence of psychopathology. At the same time, the practical relevance of emphasizing DSM thresholds to exclude subthreshold states is not clear. Subthreshold presentations are often clinically significant and warrant professional care, and scientific research so far suggests a dimensional distribution of psychiatric symptoms, making thresholds somewhat arbitrary.
A categorical distinction between disordered vs normal distress in the face of stressors therefore only crudely approximates the spectrum of mental health and mental illness. Some clinically significant states of psychological distress or impairment are context dependent, proportionate in severity to the context, and will resolve if adequate socioeconomic support is provided (eg, assistance with food, housing, employment, and health care). Other states will be disproportionate in severity and clinically significant but will require counseling and nonspecific psychological support, with possibly brief psychopharmacological interventions. And yet other states will be self-sustaining, chronic, complicated, or disabling, and will require ongoing psychopharmacological and psychotherapeutic management.
The current emphasis on screening using symptom rating scales and diagnosing using DSM criteria is likely inadequate for the task of triaging who will require or benefit from individual psychiatric treatment and of what sort. Longitudinal studies from the COVID-19 pandemic suggest diverse trajectories of depression and anxiety symptoms in adolescents,6 such that elevated symptoms may increase, decrease, or maintain severity over time. Elevated symptomatology hides different trajectories with different clinical needs. There is no substitute for a comprehensive psychiatric evaluation that pays particular attention to symptoms and their context and adopts a multidimensional framework for conceptualization. Judgments of psychopathology are not innocuous. Clinicians should be concerned that unreflective framing of distress as disordered might lead to changes in an individual’s self-conception and behaviors that in turn exacerbate or perpetuate symptoms.7
Psychosocial and environmental stressors in combination with individual vulnerability and resilience factors help explain the diverse trajectories of response and transcend biological vs psychosocial etiological dichotomies. Substantial increases in normal distress at the population level would also likely accompany increases in states of psychopathology. A subset of those experiencing stress would demonstrate new-onset psychopathology or recurrence or worsening of preexisting psychopathology. Removal of the stressor (or addressing the stressor) would no longer be sufficient on its own because the psychiatric symptomology (conceptualized as symptom networks) has a self-sustaining character that nonpathological distress does not.8
In addition to an increase in anxiety and depression symptoms, there has been a drastic increase in the suicide rate among US youth, with an increase of 57% for those aged 10 to 24 years from 2007 to 2018.9 This highlights the problematic nature of the explanation that the mental health crisis reflects a normal response to social adversity (the sick society view). At the same time, the hypothesized relevance of social causes points to the limitations of the sick individual’s view. The fact that social forces have contributed to distress and suicidality among youth neither takes away the urgency of clinical care nor eliminates the importance of social reform.
How should these insights inform clinical practice? In addition to treatment interventions, clinical care should focus on conveying an accurate understanding of the determinants of mental health problems to patients and families, including highlighting how social factors may be precipitating, provoking, or perpetuating their symptoms. Enhanced awareness of social determinants of mental health could not only combat the implicit biomedical orientation of contemporary psychiatric care but may also increase support in the general public for relevant sociopolitical reforms and funding for public health initiatives. Furthermore, while symptom rating scales and DSM symptom thresholds are valuable in clinical work, symptoms must be considered in their social context to judge clinical significance and offer treatments accordingly (including judicious use of watchful waiting). While clinicians are limited in their ability to alter social circumstances, they need to use whatever resources are available to intervene at multiple levels, both social and clinical, to help break the vicious cycle between social adversity and psychopathology.
Back to topArticle Information
Corresponding Author: Awais Aftab, MD, Case Western Reserve University, 1756 Sagamore Rd, Northfield, OH 44067 (awaisaftab@gmail.com).
Published Online: June 21, 2023. doi:10.1001/jamapsychiatry.2023.1298
Conflict of Interest Disclosures: None reported.
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