If a young person experiences depression or anxiety, psychologists say that's often a sign that they could face lifelong challenges with symptoms. If true, there is a tsunami brewing.
Poor mental health among U.S. teens was a concern before the COVID-19 pandemic, and the major disruptions to school and social life since early 2020 only exacerbated the situation. A study published this spring from the Centers for Disease Control and Prevention found that most adolescents experienced negative events during the pandemic—and those experiences were linked to higher prevalence of poor mental health and suicide attempts.
Three-quarters of high school students reported experiencing at least one adverse childhood experience in 2021, such as physical abuse, emotional abuse, food insecurity, or the loss of a parent's job. Also included were electronic bullying, dating violence, and sexual violence.
Despite growing awareness that children and teenagers can get depressed, substantial gaps remain in diagnosis and treatment. Even in states with the best access to mental health care, one in three young people goes without treatment, says Tamar Mendelson, director of the Center for Adolescent Health at the Bloomberg School of Public Health. In Texas, the worst state for treatment access, nearly three-quarters of young people with depression are not getting help.
There's no shortage of clinic- and school-based youth mental health intervention programs, yet most have not been rigorously studied. Research findings can be conflicting—some discouraging, others more promising. Taken collectively, the research suggests it is unlikely that there is one "silver bullet strategy" that will work for all children, Mendelson says, but she also emphasizes the need to better understand how to address a snowballing crisis in young people, especially girls. Rates of depression in teen girls rose from 11.4% to 23.4% from 2009 to 2019—more than triple the 3.7% rise seen in boys, according to a study published this spring in the Journal of Adolescent Health.
But there is hope, like the RAP Club. RAP (RELAX, be AWARE, and do a PERSONAL rating) is a school-based trauma-informed group intervention co-facilitated by a trained adult and young adult community member that utilizes evidence-based cognitive behavioral and mindfulness strategies.
In an initial pilot randomized study with two schools, Mendelson and her colleagues found that students in RAP Club were rated by their teachers as having more improvements in emotion regulation, academic and social competence, and classroom behavior than students in the control group. More recently, Mendelson and her colleagues received funding from the National Institutes of Health and the Institute of Education Sciences to conduct a study comparing RAP Club to an active control condition (a basic health education session). They enrolled 615 eighth graders across 29 Baltimore City public schools into the trial and assessed the students' mental health, stress, and coping at four points in time: the start of the study, following the intervention, at a four-month follow-up, and at a 12-month follow-up.
Johns Hopkins Magazine sat down with Mendelson to talk about the teen mental health landscape, the promising results of her studies, and what can be done to reverse an alarming nationwide trend.
JHM: We keep hearing the term, but how do we know there's a "crisis"?
TM: It's just so common. We know that most mental health issues start in adolescence or young adulthood, and the number of young people who are touched by some form of mental health issue is really, really high right now. It's a crisis in part because of how common an issue it is, coupled with the fact that when it's not addressed, it can interfere with how kids do at school, with their relationships, and with their ability to achieve their full potential. As teens, they're developing into who they're going to be as adults; if they're dealing with a mental health issue, it can derail the process. Part of the crisis is that there are so many young people who are suffering needlessly because we have a lot of helpful resources and supports they aren't getting.
JHM: Are they being diagnosed with post-traumatic stress disorder, depression, anxiety disorders, all the above? What can we say they're suffering from?
TM: During the peak of the pandemic, youth emergency room visits were spiking, and there were more instances of young people attempting or committing suicide. That really made it onto the national radar.
Depression rates start to increase during adolescence, especially for girls. That's where you really start to see a gender gap—and substance abuse issues also start to emerge in the teen years. Unfortunately, we do not have adequate systems for screening, monitoring, and linking young people with services. Lots of young people are not being identified appropriately. I would also argue that, more broadly, our young people are growing up in ways that do not promote their optimal health and well-being. I'm a big fan of prevention and promotion. Instead of only talking about treatment, let's invest in creating safe and supportive schools and communities for our young people. Let's make sure they have caring adults in their lives, and let's try to eliminate the traumas they currently have to deal with. Let's also teach young people healthy ways to manage stress and emotions.
JHM: In a recent paper in 'Nature,' you said that 60% of children are getting zero treatment. That's such a troubling number, knowing what can happen if mental health issues are not addressed.
TM: Exactly, and there are many countries in the world where there are almost no services. Here, we have more services, and those rates are still really high. Depending on where you are geographically, or how connected your family is, or how knowledgeable about services you are, you may be able to get access or you may be very disconnected. That's a key issue—the inequities in access and quality care.
JHM: Do we have any sense of whether it's that there aren't enough resources in places like Texas or Oklahoma, or that they don't emphasize care enough? Why is there not uniformity?
TM: That's a great question. There is a lack of resources in some areas. For example, in rural areas it's a big problem because it's often too far to drive to get to mental health resources. There are also cultural gaps in our services. For instance, there's a need for more Spanish-speaking therapists, more African American therapists, and more therapists trained in anti-racism and experienced at working with LGBTQ+ youth. Quality services are definitely lacking for some youth populations. Addressing that problem will involve changes to clinical training, including making that training more affordable, available, and welcoming for diverse populations of trainees.
Then there are insurance barriers and being able to find a therapist that you connect with because ideally you find someone that you can work well with and you feel understands you. I've heard adolescents we work with through the Center for Adolescent Health say, "Yeah, I was in therapy, but my therapist didn't really get me. It didn't really help me." I think those of us who have more resources, if it doesn't work out with one therapist, we can go to another therapist.
JHM: Not everyone can afford to go out of network if they need to.
TM: Exactly. I think for families who don't have the option to go out of network or who may not even know that they can select from different options, they may just think, "Well, therapy just doesn't work" or "This isn't for me."
JHM. Why is this crisis disproportionately impacting females?
TM: We don't really have a specific answer to that one yet. There's been a lot of research on hormonal, genetic, and biological factors. Depression is a multifactorial disorder, and there are biological and genetic vulnerabilities. Stressful life events interact with those vulnerabilities. For females, it seems likely that it's some mixture of these genetic and biological vulnerabilities combined with extra sensitivity to interpersonal events and possibly exposure to certain kinds of stressful events, but there's not an easy answer to why more girls are depressed.
It's also important to note that if you look at overall rates of mental health problems across genders, it is actually pretty comparable. Boys are more likely to be diagnosed with behavioral issues such as ADHD (attention deficit hyperactivity disorder) and what we call externalizing problems, while girls are more likely to be diagnosed with internalizing issues like depression, anxiety, and eating disorders. Many boys have internalizing issues, too, and many girls have behavioral problems, but overall, the relative rates tend to fall out along gender lines.
JHM: Is this event-based at all? By that I mean, could this stem from trauma such as the death of a loved one or maybe PTSD from observing violence?
TM: Usually there are precipitating events, something stressful that happens, as well as some preexisting factors, such as genetic or biological vulnerability. Usually, it's a combination of both. But the more serious the trauma we're exposed to, the more likely it is we'll develop PTSD and other mental health issues even if we don't have preexisting vulnerabilities. Also, depression and many other mental health problems are chronic problems, so typically if you have an initial episode of depression, that's not the end of it. You recover, but unfortunately you are 50% more likely to have a second episode. If you have a second, you're 75% more likely to have a third.
JHM: Wow, that is unsettling.
TM: Sometimes the earlier episodes have more of a stressful precipitator, and over time it may take less of that. The good news is that there are both psychosocial and medical supports for coping in healthy ways, such that many of us live with some predisposition to depression and anxiety and yet we live perfectly happy lives. We may just know how to recognize, "Oh, I'm starting to get really tense again. I know this pathway, and I know what to do differently, and I know how to take care of myself."
JHM: I'm wondering if some of the issues happening now might not present themselves immediately, but later on, when you're 30, or 40, or 50, traumatic events that happened in your adolescence will rear their heads.
TM: That can happen. Reactions to trauma can vary. Some people don't have any symptoms at first but develop them later, even years later. Some people never have any symptoms, and some people have symptoms right away. It's not exactly clear why these different pathways develop. But research shows that good support following a trauma, including being able to talk about your experiences in a safe setting, can be really helpful for long-term mental health.
JHM: Talking about the pandemic, how did it make the problem worse? Was it the isolation or was it the sheer amount of trauma because a grandmother died, a parent died, or someone lost a job?
TM: All of that. It's interesting because there were a lot of reporters asking, "What's going to happen? Is this going to be a disaster forever? Is this going to have terrible lasting effects for all these young people?" We have to see what happens, but I think for a lot of young people it was more of, "Wow, it's really frustrating that I can't go to school, I can't go to prom, I can't talk to my friends the same way." They may have felt lonely. They may have felt some depression, some anxiety, but I don't expect those stresses will have lasting negative impacts for all young people.
I suspect it's the subset of young people who experienced the trauma of losing a parent to illness or maybe parents losing jobs and losing housing, something more traumatic, who will have more serious long-term mental health struggles. My daughter, I feel, was minimally impacted. She was on the computer for a while, and then she went back to school. There were some frustrations, but I don't see really any lasting negative impact for her. Whereas some kids went through extremely difficult circumstances that will probably have more profound effects.
JHM: I can see the lack of social interaction making an already introverted young person feel worse.
TM: Then the flip side was interesting, too. I saw some kids who thrived in the pandemic because they'd been bullied at school, and suddenly they were like, "I can actually focus on schoolwork, and I can actually feel OK. I don't have to deal with all this stuff." It was helpful for some students with attention issues, too.
JHM: We know what to do. You talk about this in Nature. There's cognitive behavioral therapy and interpersonal therapy. And I guess antidepressants, such as SSRIs, can be prescribed to adolescents, too?
TM: Absolutely. You've likely heard there was a controversy about whether these drugs increase suicidal thoughts and behaviors, so there are some warnings about that, but antidepressants can be helpful for many young people as long as you have a psychiatrist who's monitoring, and it's a decision that is made with professional help. They can be very effective.
JHM: If people do get diagnosed, what's the front line of treatment that we try to get them into? Is it cognitive behavioral therapy?
TM: Those are usually the front-line types of treatments. CBT is usually the front line on the psychosocial end and then SSRIs on the pharmacological end. Of course, there are other medications and other therapies as well.
JHM: How effective are they?
TM: Many studies have shown that CBT treatments outperform other approaches. That said, CBT doesn't work for everyone, and SSRI medication doesn't work for everyone. Some people who don't respond to therapy respond to medication, and vice versa. But some percentage of people don't respond to either … there are other strategies, such as ECT [electroconvulsive therapy], that can be very effective for people who have severe depression that hasn't responded to other treatments.
JHM: I want to get into the RAP Club intervention. You and others are looking at school-based interventions where we can do more screening and we can hit a large group of people who may not have the resources. But I read that they're hit-and-miss.
TM: There isn't going to be a single intervention that solves young people's mental health needs. We need to create environments that support young people, and I believe the best way we can do that is tiered or nested supports. The more we can create environments that support young people's emotional wellness, the more we can promote health and healing on a population level and reduce the number of young people who need more intensive supports, like individual therapy.
For instance, RAP Club is what's called a universal intervention. That means it can be offered to a whole grade or school, rather than screening to identify students who have mental health issues or risk factors. A tiered system also should include additional mental health resources for the students who need more support than a universal program can give. What we found is that a lot of students had been exposed to trauma even though we hadn't screened for it, which highlights how common trauma exposure can be in many Baltimore City communities. Approximately 40% of our participants had elevated trauma symptoms at the start of the study. That's pretty intense.
When we analyzed data from our recent trial, we saw that RAP Club reduced trauma symptoms for students who participated in the intervention, as compared with the control group, by the four-month follow-up assessment, which was in the spring of eighth grade. We also found that this trauma reduction was maintained at the 12-month follow-up and even got a little bit stronger. This is when students had moved from eighth grade into high school, which is a difficult transition, so we were very pleased to see the continued intervention benefit. These are small effects because that's what you would expect for a universal prevention trial, but even small effects can have powerful impacts at a population level and can reduce the number of students who might need that next level of more intensive mental health support.
JHM: This sounds promising.
TM: The more we embed programs that support mental health into the systems that serve kids, the more we create atmospheres where they can thrive, and hopefully the less they will need to suffer through mental health problems.
JHM: Tell me more about how RAP Club works. I know some of the interactive things that you do, like having participants shake up a soda bottle and open the cap to illustrate emotions just overflowing.
TM: It's a combination of mindfulness, cognitive behavioral skills, and psychoeducation about stress and trauma that we developed from a treatment program called Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS). We spent nine months going over SPARCS together with young people and other stakeholders in Baltimore and figuring out, "Well, what would we change to make it more Baltimore or more culturally appropriate?" We basically modified it so that instead of being a treatment program for kids who were diagnosed with PTSD, it was a prevention program designed to help teens build up their emotion-regulation and coping strategies so that they wouldn't develop mental health disorders. And instead of being led by clinical psychologists, as SPARCS is, RAP Club can be led by people with less extensive clinical training and co-facilitated by young people. We initially delivered RAP Club at job training centers with young people who had left school and were engaged in job and GED training. It was going well, and then we thought, "Why don't we try and get this into schools before young people drop out, before they have this many life challenges?" We piloted it, and we got feedback from sixth, seventh, and eighth graders. We kept the core skills from the SPARCS program, but we deliver it much less like a therapy and more like a skills group.
JHM: Do they talk about their own problems?
TM: A little bit, but the discussions are structured. It's not like, "Let's all share painful stories." At the beginning and the end of every session, there's a brief meditation—basically guided breathing—and then we use "thermometers" to rate your stress, check in with yourself, how are you doing? A lot of kids would be like, "I'm great, nothing is wrong at all. I'm a zero," or "This is the worst day of my life. I am a 10." Just even building that emotional vocabulary of starting to see all the emotional states in between a zero and a 10 is a process. Starting to notice, "OK, I'm a little stressed about this test, so maybe I'm not a zero. I'm a three." That's interesting to see them interact with that. Once you can build awareness of your emotions and stress levels, you're in a much better place to use coping skills, to even know which skills to use. A lot of them talked about how that's something they would use on their own. They would do the breath exercises and check in with themselves.
JHM: Why do we think it's working?
TM: The intervention incorporates core components that have been shown in past research to be helpful, so that's a good starting point. We don't yet know which of those ingredients was the one that was most useful, or if the combination was key. We're going to start doing more analyses to try to unpack that a little bit more. We can analyze the data to see: Was it that they had improved emotion regulation from the mindfulness? Was it that they had better problem-solving skills from the CBT? Was it both? We'll see if we can get more answers.
Interestingly, boys fared better than girls. Boys had improvements in anxiety and behavior problems. Girls didn't. Boys also had larger improvements in trauma symptoms than girls. We're still looking at the data to try to understand that. Maybe girls in this age group are a little more mature and already have more of those skills.
JHM: What advice would you give to troubled teens suffering from depression or anxiety?
TM: If you're struggling with feeling depressed, hopeless, anxious, or other kinds of emotional pain, you are not alone. More than one in five teens struggles with these issues. Also, it will get better, even if it doesn't feel that way in the moment.
You might feel like disconnecting yourself from other people, but spending time with people who care about you is important, especially now. Reach out to family members or another trusted adult. Be honest about how you're feeling. If you don't have people you know well and trust, think about who else you can reach out to—maybe a school counselor, a religious or community leader, or a teacher who seems kind. You can also call a help line.
JHM: What signs should parents and teachers look for in terms of mental health issues? What are typical warning signs?
TM: Changes in how a child typically acts can be signs of distress. For instance, if your child loses interest in activities or friends they used to enjoy, spends a lot more time alone, has changes in eating or sleeping, or is much more irritable than usual. Good communication with a child can be a huge support for them and also makes it easier for you to know what's happening. So, chat with your child often, see what they're into, how they are doing. Make it clear you care about how their day is going and that it's OK for them to share negative or positive feelings with you.
JHM: Anything else you want to say in closing that might be a call to action for anyone reading this piece?
TM: First, I hope we can continue to move away from a binary and stigmatizing mindset about mental health and mental illness—that people are either "healthy/normal" or "mentally ill/crazy." We all have different emotional strengths and challenges, and many of us will struggle with significant stress and distress at some points in our lives. Mental health services can be effective, and we need to do a better job of making sure those resources are available, accessible, and culturally appropriate for all young people and families. Second, we now have evidence that most mental health disorders are preventable. As a society, we need to invest in prevention strategies, including school-based programs. We need to invest in programs and policies to promote mental health broadly for young people. This includes addressing structural racism and other forms of systemic oppression that expose some youth populations to disproportionate levels of toxic stress and trauma.