The State of Teen Mental Health

In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down with Jessi Gold, MD, MS, an assistant professor in the department of psychiatry at Washington University School of Medicine in St. Louis, and Amanda Calhoun, MD, MPH, a psychiatry resident at the Yale Child Study Center in New Haven, Connecticut, to discuss the state of youth mental health in the U.S.

The following is a transcript of their remarks:

Faust: Let's talk just state of the union, the state of teen health. It's 2023, it's May; let's start with Dr. Gold. Compared to, I don't know, 2 or 3 years ago, early in the pandemic, where are we?

Gold: I don't feel like it's ever really stopped. The way I think about mental health for all groups, but including the group that I fit in here with, which would be college students, is that our mental health and their mental health wasn't great. Then COVID came and made it worse. It's not like a COVID fairy came down from the clouds and was like, "now you have bad mental health." It was bad before, it's worse now, and whatever the stressors are might change, right?

At the beginning of the pandemic for college students, being at home and not with their friends was a stressor. But now maybe being back and reintegrating to having to be around people all the time is a stressor. So the stressors can change, but their mental health is still bad.

Faust: Yeah, I think there's a tendency to blame it all on COVID as if we didn't have any problems before.

Dr. Calhoun, let's talk about that. You probably see more patients per minute than any of us, from the resident's perspective, you're seeing so much on the ground. Not that we're not, but I think that you're just closer to more people.

Do you sense that people feel like, "Oh, the public health emergency is over, I've heard that on the news, there's reason for optimism," or is it more like, "Oh, they're going to stop caring now and we won't have telehealth?" What's the vibe there?

Calhoun: I second a lot of what Dr. Gold said in that experts were warning about an adolescent mental health crisis before COVID. We were seeing increased rates of overdoses from substance use. We were seeing increased suicide rates, and then I think COVID just exacerbated what was already there. You know, I see a lot of children in the hospital, so I'm seeing kids who are in crisis, obviously, because they're in the hospital.

We are seeing a decrease in mental health-related emergency visits. So we're seeing a decline, which is good, less kids in the emergency room. That doesn't necessarily mean that kids are doing great, though. It just means that less are coming to the emergency room, which could be a good thing and it also could be a bad thing because it means they're not getting mental health help. We know that most adolescents that have mental illness will never see a child psychiatrist like me.

Specifically, my expertise is in the mental health of Black Americans, specifically Black children and adolescents. When you talk about adolescent crisis, there's been a Black youth crisis for over 20 years now, and that is not showing any signs of improvement.

So I have a lot of concerns about the kids that I see in the hospital and kids in general. I have a lot of concerns about the fact that we're still seeing widely televised violence disproportionately towards Black Americans. I have a lot of concerns about my Asian-American patients who are still experiencing downstream effects of anti-Asian hate, my transgender patients -- I mean, there's just a lot going on right now.

I think as physicians, trying to tell us to be apolitical, be apolitical -- but you can't, because kids and adolescents want to talk about what's going on in the world right now. I think they're just waiting for us as doctors to give them permission to talk about the things that they want to talk about and I think we need to talk about.

Gold: Can I piggyback off that? I just wanted to say that psychiatry, maybe more than all fields in medicine, has no choice but to get into those conversations, right? Because everything that's bringing somebody into their office is what's going on in their lives, and it's very hard. That's housing, that's food, that's access to care, that's are you not allowing them to get the care they deserve in the state that they live in? Whatever it is, it's very, very hard in the fields that we do to pretend that doesn't exist.

That's what's bringing them in as their trigger. So we can't ignore that in our fields at all. And if you do, frankly, I don't actually think you're doing a very good job.

So I agree with Amanda that it's just really challenging to say something like, "we can't be political," because some of this stuff shouldn't be political, but on top of that, that's what our patients are talking about -- college kids in particular.

If you look at the Vietnam War as an example, college kids feel things and feel things deeply and always have. It's a group of activism. It's a group that wants to change the world, but not wait for the world to change, right? That affects their mental health because every day they wake up and there's more and they didn't change it. That's really, really hard.

To work in that group and not watch the news and not know what's going on and not be able to talk about it is just impossible, honestly.

Faust: I really, really wanted to talk about social media and the news and follow up with what Dr. Calhoun was saying a moment ago, because I'm really truly on the fence on this.

On one hand, I think we all know that social media is a way for people to connect. I literally have met some of my closest friends from Twitter and that's not fake. I mean, some of it turns out to be you meet and actually it's more of a Twitter relationship or friendship or we work on papers together, but we don't have drinks with our families or whatever.

Then other times it's like, oh no, this was a seamless transition. It's the opposite of loneliness, it's like access to the whole world.

On the other hand, you're constantly being bombarded with messages. What I want to ask to follow up on a comment that you made is that this has been going on for a long time. I almost feel from my perspective that there was a downplaying or erasure of the problem that you're talking about, and now it's out there every day and it's in your feed. In a way that's good, because we don't want to hide it. But can there be a point where kids are looking at this and it seems more overwhelming and scarier in a way that I wouldn't say makes it worse, but just adds stress?

Calhoun: Yeah. As with most things, everything in moderation, right? When social media becomes your whole world and you can't have a face-to-face conversation with another human, which I have encountered not just in adolescents but adults as well, I think it becomes a problem because you need to be able to have conversations with humans in real life.

But I also think that relying on social media for networking and being able to connect with people about things that are very important can be actually very helpful. Especially if you are an adolescent from a marginalized background and you may be in a situation where no one around you really supports you. Sometimes online communities can be lifesaving, but there's everything and anything out on the internet.

So I think it's important to have some monitoring, especially for adolescents. It's kind of a constant battle between, you don't want to cause angst amongst the adolescents where they're over-restricted on social media by their parents or their caretakers, but there needs to be a little bit of monitoring because you don't exactly know what they're doing and what they're being exposed to. There are some pretty creepy websites out there.

As far as the widely televised violence against Black people, I've spoken about this multiple times and I'm pro recording the violence and the racist violence -- we need it for evidence and it's important -- but I'm not pro at it being so widely televised that I click on a website and suddenly a video has started of another Black person being murdered.

Studies are starting to come out that show that when this happens, meaning a widely televised murder of a Black American, Black Americans do suffer mental health-wise for a few days after that and possibly longer. There are new studies that actually showed that white Americans did not have side effects, which I think is important to put out there because, why? Is white America becoming more desensitized to violence towards Black Americans? Because I will tell you, we as Black Americans are not desensitized to it. It's very hurtful. But the fact that in that study, white Americans had no negative side effects from watching that is concerning to me.

Again, is it really healthy or helpful for either side to continue to see this violence? Can we talk about it? Can we write about it without having it being in our faces?

I think, to bring it back to adolescents, they are most definitely seeing all of this. That's very difficult when you're growing up as a Black child to be seeing that happen to people your age and to think, "oh my gosh, could this happen to me?" And it could. Being able to have those conversations with adolescents, I think is really important because they are being exposed to this stuff.

I think the worst thing to do is pretend like it isn't a thing. Like Jessi said, I don't think you're a good psychiatrist either if you're like, "Oh, let's not talk about racism. Let's just talk about your mental health." Huh? It is a stressor. It is a trigger. You can't not talk about housing with your patient. So I think we have to talk about this, and social media is honestly a good way to open the conversation.

Gold: I think the thing with social media is a lot of the onus does fall to the companies to have some control over what's being put out there.

Because we also have kids who have self-harmed who go to social media and they can find more pictures of self-harm and they use key words and they know what they can search. We have kids that have eating disorders and learn what not to eat and the best foods to trick doctors from the internet, right? A lot of our patients are going to social media for that kind of content. So we need to be able to not have that be content that they can get exposed to.

But in the same realm, how many hours is too many hours on social media, when do screens start [for kids]? All of that data is horrible. For you, who really cares about data, Dr. Faust, it is not good data. There's some data that says it's really bad for your mental health. There's some data that says it's fine. It's very hard to say when the screen time age should change and what we should be advising parents.

I mostly am in a risk-benefit conversation with that, which is, what's your mood when you're on it? How's your concentration? How's your sleep? Is it affecting your interpersonal relationships in some capacity where you're not actually talking to real people because of it? But if you're a person who has social anxiety, you might never have had those conversations if social media didn't allow you to start it.

So as much as there's a developmental risk to learning behaviors and communication through a device, there's also benefits to it you wouldn't get otherwise. I think we have to be really mindful that the data is not great and not very mixed because it is very complicated.

People really want to say that teen rates of suicide and self-harm are higher simply because of social media. That is far too simple, but it is a factor. I think we have to treat it like a factor, but there's no way you could say it's the only [factor]. It's impossible.

Comment