Adolescent mental health in crisis

We concur with Gunnell et al.’s discussion on the need for improved understanding of risk factors influencing the mental health trends of adolescents.[1] We would like to extend this focus to include emerging adults (18-25 years) rather than adolescents alone (12-18 years). Whilst we acknowledge that Gunnell et al. did not explicitly report an age range for adolescence, the extended period of transition to adulthood is critical for the development of potentially chronic adult mental disorders.

There are numerous reasons to support this approach. Three-quarters of mental disorders have their onset prior to 24 years of age,[2] challenging the appropriateness of a paediatric-adult model for mental health care that creates major service discontinuity at the heart of the period of greatest need. In addition to adolescence, increasing rates of psychopathology have been observed across the emerging adult years,[3] consistent with the Universities UK report cited by Gunnell et al. From a broader developmental and biological perspective, the traditional conceptualisation of “adolescence” is less relevant to today’s generation of young people with the transition to independent adulthood now continuing until the mid to late 20’s.[4,5]

We agree with Gunnell et al. that greater research in this area is needed to develop a long-term framework for the mental health of young people that includes effective early intervention and preventive strategies. However, focusing on risk factors is only one part of the solution. A further area that urgently needs addressing is reforming systems of care for young people who demonstrate the greatest need for care that is often unmet. In Australia, 16% of individuals with anxiety and depression access minimally adequate evidence-based care, with young adults less likely to access treatment.[6] To adequately address the current and evolving needs of young people, new models of care need to be established that are evidence-based, culturally appropriate and guided by developmental periods of greatest need (up to 25 years) to open up primary care to young people and eliminate discontinuities in care (i.e. transitioning to an adult service) at peak periods of mental disorder onset.[7,8] Without redesign and reform of service structures, the capacity needed to deliver evidence based interventions will not be developed and we will continue to fail to meet the needs of young people and their families.

References
1. Gunnell D, Kidger J, Elvidge H. Adolescent mental health in crisis. BMJ 2018;361:k2608. 10.1136/bmj.k2608
2. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602. 10.1001/archpsyc.62.6.593
3. Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics 2016;e20161878. 10.1542/peds.2016-1878
4. Arnett JJ, Zukauskiene R, Sugimura K. The new life stage of emerging adulthood at ages 18–29 years: implications for mental health. Lancet Psychiatry 2014;1:569-576. 10.1016/S2215-0366(14)00080-7
5. Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet Child Adolesc Health 2018;2:223-228. 10.1016/S2352-4642(18)30022-1
6. Harris MG, Hobbs MJ, Burgess PM, et al. Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults. Med J Aust 2015;202:185-189. 10.5694/mja14.00297
7. McGorry PD, Goldstone SD, Parker AG, Rickwood DJ, Hickie IB. Cultures for mental health care of young people: an Australian blueprint for reform. Lancet Psychiatry 2014;1:559-568. 10.1016/S2215-0366(14)00082-0
8. Iyer SN, Boksa P, Lal S, et al. Transforming youth mental health: a Canadian perspective. Ir J Psychol Med 2015;32:51-60. 10.1017/ipm.2014.89

I hope the authors will forgive me for the heretical, non-statistical response born out of ignorance and faulty memories. But, please, will they and others please enlighten me? (There may be other ignorant folk unwilling to confess ignorance.)

1. Looking at the references, I could not discern any from Eire (largely English speaking neighbour with a “ soft border” with the UK).
Does adolescent mental heslth there also seem to be in crisis?

2. I pass a cafe or a restaurant open to the public gaze. I see young people sitting tapping the smart phone with a piece of cake, or a coke or even a coffee on the table in front.
I have asked some of them (known to me) how they can converse when they are sending messages to someone else. “ You do not understand. They ARE conversing - with each other, sitting next to each other, by TEXT.”
I LIKE to be a able to SEE the person I am talking to - his/her facial expression is essential to me in a conversation.
I venture to suggest that here in Gross Britania, the youth are suffering mentally because of this misuse of “technology”. They tell me I am electronically challenged. Correct.

3. We have professors of global public health. Could they throw some light - bright if possible, or at least a flickering glimmer - on the state of mental health in Denmark, the Netherlands, Italy?

4. Provided there are no glaring differences in other aspects of life-style, does religion have an influence on the mental health of adolescents?

5. In Bristol at least there will be in the local library the annual reports of the MOH cum PSMO, from years before 1974.
Any comparison between 1972 and 1992, then 2012?

Thank you