Youth mental health crisis with Sandra DeJong, MD, MSc

Youth mental health crisis with Sandra DeJong, MD, MSc AMA's Moving Medicine series features physician voices and achievements. Learn more in this discussion about the youth mental health crisis. American Medical Association

Dr. DeJong: Yeah, so it really is unprecedented in my experience to have both this emergency declaration and the surgeon general's advisory. And I think it really is because the situation itself is unprecedented. So what makes it an emergency? We have much higher rates of things like anxiety, depression, suicide.

But it's also, really, the impact of the psychosocial effects of COVID, so things like teenagers confronting illness and death, family stress due to unemployment and financial pressures, increased rates of domestic violence, increased use of parental substance abuse. At the same time, kids have been out of school, fewer adults monitoring them. Schools have been closed.

And we have to remember that lots of kids around this country get food from school, get mental health services from school. They've been cut off from their peers, which is critical for youth to develop that sense of identity, which this stage is really all about. Academic skill loss has been a factor, disengagement from school and, really, just lots of loss of structure and routine.

And we really don't know what the effect of this is going to be over time. We think that vulnerable youth are going to be more at risk, those who are already at risk. But, really, I think we have to think about this as a whole generation at potentially increased risk.

Unger: Wow, no shortage of drivers from that list you just gave. When you look at where we are right now, what you see as the biggest risks to adolescents today and has this shifted over time?

Dr. DeJong: Yeah, I think things are getting better. Schools are mostly back in person. But there's a lot of uncertainty as to what life will look like in terms of schools and health care and all of that. And we still have a really ... for example, in my clinic, my hospital clinic has the biggest waiting list we've ever had. So things still feel pretty tough in the mental health arena.

I think this persistent high stress and loss at this key stage of development is likely to have a long-term sequelae. It may even have epigenetic impacts on brain development. And we will have—and get passed over succeeding generations. So there's a lot going on with this.

And then it's been compounded by other kinds of psychosocial stressors, so, certainly, what's been going on with climate change and the impact of that on youth, the activity around systemic racism. So there's a sense of youth having been really burdened. And I think while they've realized that things like vaccinations and antiviral medications can help take care of the physical symptoms of COVID, the mental health and the social-emotional impacts have been much harder to break free from.

Dr. DeJong: Yeah, I think things are getting better. Schools are mostly back in person. But there's a lot of uncertainty as to what life will look like in terms of schools and health care and all of that. And we still have a really ... for example, in my clinic, my hospital clinic has the biggest waiting list we've ever had. So things still feel pretty tough in the mental health arena.

I think this persistent high stress and loss at this key stage of development is likely to have a long-term sequelae. It may even have epigenetic impacts on brain development. And we will have—and get passed over succeeding generations. So there's a lot going on with this.

And then it's been compounded by other kinds of psychosocial stressors, so, certainly, what's been going on with climate change and the impact of that on youth, the activity around systemic racism. So there's a sense of youth having been really burdened. And I think while they've realized that things like vaccinations and antiviral medications can help take care of the physical symptoms of COVID, the mental health and the social-emotional impacts have been much harder to break free from.

Unger: That is, I mean, a terrible amount of burden. And the generational impact that you talked about is something serious and, I guess, something we'll see play out. When we talk often about different topics related to the pandemic, there's kind of a common thing, which is there was something that was already not great beforehand that was exacerbated by the pandemic.

When you take yourself back pre-pandemic, were you already seeing signs in your practice that teen mental health was on a decline? Or were you seeing trouble spots before COVID hit?

Dr. DeJong: Yeah, so it's absolutely true, I think, that things were already in decline, and that COVID seems to have accelerated and exacerbated that decline. So I started outpatient practice in 2001. And at that time, we were already seeing the rates of anxiety, depression, suicide, substance use going up in this country. And there's been a lot of speculation about the cause of that, what role social media had and so forth. But things were already getting worse.

And I would also say that there was already back then, the system for youth mental health care was already struggling. And I remember very vividly starting my practice. And within a very short period of time, I had a six-month wait list. So this has been going on for some time, yeah.

Unger: So a real shortage on the physician end in this space?

Dr. DeJong: Absolutely. So we know, unfortunately, that we have a national crisis in terms of the shortage of child psychiatrists. We have only 14 child psychiatrists per 100,000 youth in this country. And about half of youth aren't getting care for their mental health problem for those who need it, so big, big access problem, yep.

Unger: Dr. DeJong, with more teens struggling with mental issues, like you've outlined, and not offset whatsoever by the supply of actual folks that can help them, is stigma still an issue in this population or a barrier to getting teens asking for help or getting help?

Dr. DeJong: It's interesting, in my experience, teens have, in general, been much more open to talking about mental health concerns than have the parental generation. And I actually think what's shifted is that adults are now more open to thinking about it. Everybody from Michelle Obama reporting that she was depressed to physicians themselves have been claiming their own mental health concerns in public. And I think they are now more open to listening to what youth have been talking about for some time.

I would just add to that, though, I think it's important to recognize that there are certain groups for whom mental health issues still are highly stigmatized. And we really have to be particularly vigilant about those groups.

Unger: Do you want to talk specifically more about that?

Dr. DeJong: Well, so, for example, we know that in Asian American communities, the idea of having a mental health problem and going and seeking mental health care is a huge source of shame, potentially, in their communities. We, in my clinic, work with a lot of Asian American youth and, again, it's really not part of their culture to get mental health care. So I think things are overall getting better. And I think as the overall stigma decreases, hopefully, it's likely to decrease for everybody. But we do need to be sensitive to that issue.

Unger: Like with, again, so many things during the pandemic data and having enough data to really guide decisions has been really important in kind of catching up. When you look at this crisis, do you feel like we have enough data for the profession as a whole to respond well? And if not what, questions still are yet to be answered?

Dr. DeJong: Yeah, I have to say when you look at youth mental health data, in my opinion, it's just not as good as one would wish. We have data that are based on surveys of self-report, for example, by parents and kids and a lot of synthesis of that data. But what we don't have is systemic data. Even when you compare systems of care across states, they use different terminology for the same kinds of services. And so trying to do comparisons is really quite tricky.

We also don't have enough longitudinal data. So we really need to know what's been the impact and what will be the impact of COVID on youth over time. So that's going to take years of study. And those kinds of large longitudinal studies are just difficult to do.

And I think we need to understand better where the holes in our system of care. And I would love to know where are the communities where things have gone better than we might have predicted and what were they doing right. What works? What fosters resilience in communities and populations? I think that—

Unger: Have you heard anything to that effect that's promising?

Dr. DeJong: Well, I think there are a lot of efforts underway. I think what I'm seeing, which does really give me hope, is an emphasis on community resilience and building up community systems of support, which I think is really going to be where the money is.

Dr. DeJong: Well, I think in the short term, we need to try to pivot to a more positive, future-looking stance. We're not going to be in this forever. I mean, it's going to be part of a new normal. But things are getting much better.

I really encourage people to connect with others. That was missing so much during COVID. And I think it's such a huge part of our mental health to feel connected and part of a greater whole. So I often refer people to community efforts or encourage them to have family events or get together with their friends, those kinds of things as a way to sort of pull together after this really challenging time.

But, look, really, youth mental health, child mental health, our system is more like Swiss cheese than anything else. It's got a lot of holes in it. And I think we're going to need to really look at ensuring that we have a system of care that isn't just about beds.

I know we hear a lot about the boarding crisis and kids waiting for beds. But we really need to be looking at the community level, schools, law enforcement, community organizations up through primary care to urgent access to care. So, hopefully, this new 988 hotline will be helpful and then looking at the more acute services for care.

But if we can get in early to provide kids what they need, I don't think we're going to need as many hospital beds as we think. And that's really critical because we know there's no health without mental health, and our youth really truly are our future. And we really do think they're at risk in ways that we are only just beginning to understand. And so we really need to be close and watchful and be there for them.