Mental Health Crisis in Youth—Sick Individuals or Sick Societies?

Aftab & Druss (2023) in JAMA Psychiatry

A viewpoint paper of mine, co-authored with Benjamin Druss, Addressing the Mental Health Crisis in Youth—Sick Individuals or Sick Societies?, has been published online ahead of print in JAMA Psychiatry. I’ll post some brief excerpts below to convey the essence of the article. (As always, feel free to email me if you need access to the full text.)

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“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. 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 disorders while the other seeing the increase in psychological distress in youth as reflective of sociopolitical adversity and disorganization. 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.”

“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. 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.”

“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… 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.”

“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.”

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