Machine Translated by Google
BMJ 2018;361:k2608 doi: 10.1136/bmj.k2608 (Published 19 June 2018)
Editorials
Adolescent mental health in crisis
We need to understand the causes to inform prevention
David Gunnell professor 1 2, Judi Kidger lecturer in public health 1, Hamish Elvidge chair
1Department of Population Health Sciences, University of Bristol, Bristol, UK; 2National Institute of Health Research Biomedical Research Center at the University Hospitals Bristol
NHS Foundation Trust and the University of Bristol, Bristol, UK; 3The Matthew Elvidge Trust, Hartley Wintney, UK
Universities UK recently reported a fivefold increase in the
number of students disclosing mental health conditions since
2007 (from 9675 in 2007-8 to 57 305 in 2017-18) and growing
pressures on student mental health services, despite only
a modest rise in student numbers A . growing number of UK and
first
international studies show that affective disorders in young
people are significantly rising, particularly among girls and
2
young women. A recent UK analysis reported a 68% increase
in hospital self harm presentations in 13-16 year old girls
between 2011 (45.9 per 100 000) and 2014 (76.9 per 100 000).3
Causes of the escalation are uncertain. Some studies point to a
rise in presentation and diagnosis rather than a true increase in
incidence.4 More people self reporting problems may partly
reflect greater willingness to share feelings, such as suicidal
thoughts, due to better mental health literacy. If the situation
reflects a real deterioration in the mental health of young people,
there are several possible explanations.
The young people affected are “generation Z,” born in the mid
1990s and early 2000s. They grew up in the age of social media,
the great recession (2008), increases in family breakdown,
growth of international terrorism, and, in the UK, student debt
5
and predicted gaps in prosperity between them and their parents.
Academic pressures at school cause stress, and the UK
government has focused on testing in recent years. Many of
these phenomena affect both boys and girls, although some
factors, such as school performance pressures and lower family
income, may be more likely to affect girls.
sixty seven
We need to look beyond well recognized risk factors for poor
mental health, such as abuse and trauma, to problems that have
arisen in recent decades, that affect countries beyond the UK,
and that affect girls more than boys.
One explanation is the rise in young people's use of social media
after the launch of Facebook (2004), Snapchat (2011), and other
platforms. Social media use may result in less face to face
communication, overdependency on being “liked” for social
validation, 8 and pressure to keep up with discussions 24 hours
9
a day, leading to poor sleep. Recent research provides some
support for these concerns, with greater effects on girls than
10 11
boys. But we need a deeper understanding of the risks and
Correspondence to: D Gunnell djgunnell@bristol.ac.uk
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 1 of 2
EDITORIALS
3
benefits, and we must balance concerns against the positive
aspects of internet access, including crisis support, reduced
social isolation, and better provision of therapy.
twelfth
The UK government's recent green paper on children and young
people's mental health confirmed its previous commitment of
£1.4bn (€1.6bn; $1.9bn) and an additional £300m to this area
13
over five years. It is heavily focused on improving funding for
frontline mental health services and training non-health
professionals such as teachers to recognize and help those
experiencing problems, as well as incentivising schools to
appoint a mental health lead.13 Importantly, this shifts some of
the responsibility for mental health from health services to
schools , but as select committees' responses to the green
paper have emphasized, it will place an additional,
14
potentially unwelcome pressure on already stretched teachers.
Although this attention on adolescent mental health is welcome,
we urgently need research to better understand the underlying
causes of recent trends in presentation and incidence to underpin
the development of effective strategies—an area given little
emphasis in the green paper.
13
Half of all mental
illnesses begin before age 14, and research into the mental health
of young people is underfunded.15
Studies could include natural experiments to compare mental
health between populations that are differentially exposed to
possible risk factors. Longitudinal studies are needed to clarify
factors associated with risk and resilience—in particular, sex
differences in exposures and mental health outcomes. Because
of rapid changes in the environment and information technology,
we must take care to ensure that findings remain applicable to
the cohorts at risk.
Qualitative research could illuminate differences in girls' and
boys' exposure to possible risk factors, such as social media
and school pressures, as well as the effects these have. Causality
is difficult to determine using observational research, so
intervention studies, controlling exposure to one or more target
risk factors, may be one way forward.
This research is essential for developing a long term framework
for children and young people's wellbeing, based on the
principle that our mental health must be protected in the same
Subscribe: http://www.bmj.com/subscribe
Machine Translated by Google
BMJ 2018;361:k2608 doi: 10.1136/bmj.k2608 (Published 19 June 2018)
way that we protect our physical health. A whole population
approach is required, including schools, universities, workplaces,
job centers and homes, so that emotional wellbeing and mental
health becomes the foundation of our children's experiences
throughout life's stages and transitions. This would build a
generation of young people with a deeper understanding of the
importance of their own and others' mental health, the skills
required to keep healthy, and an awareness of the signs of being
unwell, so that they can seek help earlier for themselves and
respond better to others in difficulty.
Competing interests: We have read and understood BMJ policy on declaration of
interests and declare the following interests: DG is a Samaritans trustee and a
member of England's National Suicide Prevention Advisory Group. JK is a member
of Mental Health First Aid's Expert Reference Group for the Schools' programme.
HE is chair of the Matthew Elvidge Trust and the Support after Suicide Partnership;
he is a member of England's National Suicide Prevention Advisory Group;
Universities UK Mental Health National Advisory Board; and the National Suicide
Prevention Alliance Steering Group.
Provenance and peer review: Not commissioned, peer reviewed.
first
Universities UK. Minding our future: starting a conversation about the support of student
mental health. May 2018. http://www.universitiesuk.ac.uk/minding-our-future.
2 Collishaw S. Annual research review: Secular trends in child and adolescent mental
health. J Child Psychol Psychiatry 2015;56:370-93. 10.1111/jcpp.12372 25496340
3 Morgan C, Webb RT, Carr MJ, etal . Incidence, clinical management, and mortality risk
following self harm among children and adolescents: cohort study in primary care. BMJ
2017;359:j4351. 10.1136/bmj.j4351 29046278
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 2 of 2
EDITORIALS
4 Wiens K, Williams JVA, Lavorato DH, et al. Is the prevalence of major depression
increasing in the Canadian adolescent population? Assessing trends from 2000 to 2014.
J Affect Disord 2017;210:22-6. 10.1016/j.jad.2016.11.1018 28012349
5 Barr C. Who are Generation Z? The latest data on today's teens Guardian 10th December
2016. https://www.theguardian.com/lifeandstyle/2016/dec/10/generation-z-latest-data
teens
6 West P, Sweeting H. Fifteen, female and stressed: changing patterns of psychological
distress over time. J Child Psychol Psychiatry 2003;44:399-411.
10.1111/1469-7610.00130 12635969
7 Patalay P, Fitzsimons E. Mental ill-health and wellbeing at age 14 – Initial findings from
the Millennium Cohort Study Age 14 Survey. May 2018. http://www.cls.ioe.ac.uk/
page. aspx?&sitesectionid=2419&sitesectiontitle=MCS+Age+14+initial+findings
8 Children's Commissioner. 2018. Life in likes. Children's commissioner report into social
media use among 8-12 year olds. https://www.childrenscommissioner.gov.uk/publication/
life-in-likes/
9 Woods HC, Scott H. #Sleepyteens: Social media use in adolescence is associated with poor
sleep quality, anxiety, depression and low self-esteem. J Adolesc 2016;51:41-9.
10.1016/j.adolescence.2016.05.008 27294324
10 Twenge JM, Joiner TE, Rogers ML, Martin GN. Increases in depressive symptoms,
suicide-related outcomes, and suicide rates among US adolescents after 2010 and links
to increased new media screen time. Clin Psychol Sci
2018;6:3-1710.1177/2167702617723376.
11 Booker CL, Kelly YJ, Sacker A. Gender differences in the associations between age
trends of social media interaction and well-being among 10-15 year olds in the UK. BMC
Public Health 2018;18:321. 10.1186/s12889-018-5220-4 29554883
12 Marchant A, Hawton K, Stewart A, etal . A systematic review of the relationship between
internet use, self-harm and suicidal behavior in young people: The good, the bad and
the unknown. PLoS One 2017;12:e0181722. 10.1371/journal.pone.0181722. 28813437
13 Department of Health, Department for Education. Transforming children and young
people's mental health provision: a green paper. 2017. https://assets.publishing.service.
gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_
children_and_young_people_s_mental_health_provision.pdf
14 O'Dowd A. MPs criticise government's child mental health plans as unambitious. BMJ
2018;361:k2063.
15 Dubicka B, Bullock T. Mental health services for children fail to meet soaring demand.
BMJ 2017;358:j4254. 10.1136/bmj.j4254 28963350
Published by the BMJ Publishing Group Limited. For permission to use (where not already
granted under a license) please go to http://group.bmj.com/group/rights-licensing/
permissions
Subscribe: http://www.bmj.com/subscribe