Intended for healthcare professionals


Adolescent mental health in crisis

BMJ 2018; 361 doi: (Published 19 June 2018) Cite this as: BMJ 2018;361:k2608
  1. David Gunnell, professor12,
  2. Judi Kidger, lecturer in public health1,
  3. Hamish Elvidge, chair3
  1. 1Department of Population Health Sciences, University of Bristol, Bristol, UK
  2. 2National Institute of Health Research Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, UK
  3. 3The Matthew Elvidge Trust, Hartley Wintney, UK
  1. Correspondence to: D Gunnell d.j.gunnell{at}

We need to understand the causes to inform prevention

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.1 A growing number of UK and international studies show that affective disorders in young people are rising substantially, particularly among girls and young women.2 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 and predicted gaps in prosperity between them and their parents.5 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.67

We need to look beyond well recognised 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 a day, leading to poor sleep.9 Recent research provides some support for these concerns, with greater effects on girls than boys.1011 But we need a deeper understanding of the risks and benefits, and we must balance concerns against the positive aspects of internet access, including crisis support, reduced social isolation, and better provision of therapy.12

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 over five years.13 It largely focused on improving funding for frontline mental health services and training non-health professionals such as teachers to recognise 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 emphasised, it will place an additional, potentially unwelcome pressure on already stretched teachers.14

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 prevention 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 way that we protect our physical health. A whole population approach is required, including schools, universities, workplaces, job centres 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.


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