Youth mental health: risks and opportunities in the digital world
McGorry et al1 present a call to action to redesign youth mental health care and conceptualize youth psychiatry as a distinct discipline. Their proposed framework for youth mental health care contains four key elements: a) a focus on prevention and early intervention, with youth mental health services embedded in primary care and community settings; b) services co-designed with young people to be accessible, engaging and destigmatizing; c) blending the benefits of digital technology, to provide accessibility and scale, with human online and face-to-face support to promote youth engagement; d) extending the age boundary of youth mental health provision to cover the period of extended brain maturation in the “new adolescence” and the peak risk period of onset of mental disorders up to age 25.
The urgency of this task is driven by a global youth mental health crisis, and the failure of traditional models of mental health care to meet this demand. In the UK, one in eight young people have a mental health disorder, and one in four young women aged 17 to 19 have significant depression or anxiety, with half of those having self-harmed2. Non-suicidal self-harm has nearly tripled over the past 10 years3, while suicide rates per 100,000 adolescents have almost doubled4. Depression represents the leading cause of disability-adjusted life years lost in young people, resulting in a major societal and economic burden extending across the lifespan.
The peak period for the onset of depression is adolescence and young adulthood, and most adults with recurrent depression will have first experienced it before age 255. However, the growing demand for youth mental health support and intervention far outstrips the capacity of traditional mental health services to respond. In the UK, only 30% of young people with clinically significant depression or anxiety receive any help or professional support, and up to 90% of youth with mental disorders in some low-income countries receive no mental health care6.
The youth mental health crisis has coincided with the emergence over the last decade of a new “digital environment”. Digital technology presents major opportunities to scale-up and transform youth mental health services, but also potential risks for youth mental health and well-being, which, if the mechanisms were better understood, could create targets for preventive psychiatry.
In this new digital environment, young people's communication primarily takes place online or via social media. Most (83%) of UK's 12 to 15-year-olds own a smartphone, with over two-fifths of girls and one-fifth of boys aged 14 using social media for three or more hours a day7. For many young people who are isolated and have mental health problems, social media can be an important source of health information, knowledge and social support. However, social media use has also been linked with depression, suicide and self-harm, particularly in girls and marginalized groups7. Potential mechanisms include social isolation, disturbed sleep, attentional distraction, cyberbullying, pressures to conform to idealized lifestyles and body images, and the influence of screen-media activity on brain maturation.
Nevertheless, not all young people are at risk of mental health problems with social media, and currently there is little understanding of what factors make some youth more vulnerable than others. Policy initiatives and potential preventive interventions are hampered by uncertainty regarding mechanisms and the direction of effects linking use of digital technology to risks for mental health disorder in young people. The COVID-19 pandemic and resulting “lockdown” has been associated with increased mental health problems and greater online activity in young people. While the need of youth to access trusted support online is greater than ever, social media platforms are not designed to meet mental health needs of young people.
Digital technologies have the potential to transform youth mental health services through improved access to evidence-based resources and interventions, and by automating parts of diagnostic, monitoring and treatment pathways. They can connect young people with peers, mentors and therapists, potentially bridging the mental health treatment gap through novel, tailored, flexible and less stigmatizing treatments. However, this potential is still largely unrealized. Few digital interventions are included in routine care, and poor adherence is seen in those that are.
Industry-led innovations often lack a research evidence base and youth co-design (which is crucial to ensure that products fit with needs and lifestyles, and to tackle non-adherence). Numerous mental health and well-being apps exist, but most have no evidence base and some could even be harmful8. Meanwhile, academic-led evidence-based digital interventions are available, but few, if any, have shown sustained uptake and engagement in real-world settings. Effective, usable and accessible digital innovations could redress the imbalance of global health inequalities and ensure that evidence-based mental health interventions reach young people who need them most.
McGorry et al provide a number of examples of youth mental health services which have embraced digital technology and provide digital service platforms, such as headspace in Australia. Evidence for specific digitally-enabled, human-supported interventions is emerging, including MOST (moderated online social therapy)9. While youth mental health services and the associated digital interventions such as MOST were originally inspired by the aim to intervene early in the course of first-episode psychosis and other severe mental illness, the focus of these digital services has now broadened to include a wider range of youth psychopathology.
It is important to consider a number of limitations and unresolved questions facing the new systems of youth mental health care presented by McGorry et al. First, establishing these new services could result in diversion of resources away from other services for young people which fall outside their clinical remit or organizational boundaries. Second, it remains unclear how best to personalize the level of human support needed for young people who access digital mental health services, and how best to sign-post young people engaging with digital platforms to the most effective interventions. Third, a flexible, developmentally sensitive approach is needed to meet the changing psychological and social needs of youth from ages of 10 to 25. For example, younger adolescents engaging with digital interventions have been shown to benefit from parental engagement and support in their therapy, while, for older adolescents and young adults, peer-support may be of increasing relevance. Platforms and youth services need to reflect these developmental variations.
Fourth, to date, there has been little attention on interventions that focus on building young people's resilience to online harms such as cyberbullying. Youth mental health services need to address the specific challenges of the digital environment for young people with different mental health vulnerabilities, including depression, risk for self-harm, eating disorders and attention-deficit/hyperactivity disorder. As well as designing a wider digital environment that supports young people's mental health, we need services to acknowledge that youth with mental health problems may engage with the online world differently, and that they need help to develop the skills and competencies to build resilience and maximize the benefits of the digital world for their mental health and well-being.
