Ask an Expert: Youth Mental Health With Janet R. Cummings
By Karina Antenucci
In October 2022, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association released a joint statement declaring a mental health emergency in youth mental health.
The most recent data from an annual national survey that is conducted by the Substance and Mental Health Services Administration (SAMHSA) shows that one in five adolescents (20.1 percent) had had at least one episode of major depression in the past year. A study published in 2022 found that the prevalence of major depression of adolescents had nearly doubled over a 10 year period (2009-2019) from 8.1 percent to 15.8 percent.
“I am extremely concerned about the overall trend of worsening child and adolescent mental health. It is great that there has been more awareness, attention, discussion, and focus on youth mental health more recently but this trend goes back more than 15 years ago and shows no signs of slowing down,” says Janet R. Cummings, PhD, professor of health policy and management, deputy director of the Southeast Mental Health Technology Transfer Center (SMHTTC), and director of SMHTTC’s School Mental Health Initiative at Rollins.
Here, we sit down with Cummings to discuss the factors contributing to the decline of youth mental health and what can be done about it.
What is the biggest issue facing youth mental health today?
The biggest problem we are seeing is the prevalence of mental health disorders reaching crisis levels. If you’re an educator working with adolescents, you need to know that 20 percent of the teenagers in your class or school, on average, will have an episode of major depression during the year. In addition, a recent CDC report using 2021 data from the Youth Behavior Risk Survey found that 22 percent of high school students experienced suicidal thoughts, 18 percent made a suicide plan, and 10 percent reported making a suicide attempt during the past year. If you are a parent of a teenager, you need to know that even if your kids are not personally affected by these challenges, there is still a good chance one of their friends will be.
It’s also important to keep in mind that these statistics are for the population on average, and there are groups and communities that will face even greater risk. For example, data from the that same CDC report indicated that 30 percent of female high school students had suicidal thoughts in the past year, compared to 14 percent of male students. Risk factors for poor mental health can also vary by race/ethnicity, family income, sexual orientation, and across communities.
What role has social media played in youth mental health struggles?
Although social media use can have some benefits for youth, there is also a growing body of evidence on the potential risks of social media. Findings from this literature are summarized in the recent advisory by the surgeon general, “Social Media and Youth Mental Health.” For example, a 2022 study in the American Economic Review found that as Facebook rolled out across college campuses, mental health among college students on those campuses deteriorated. My hope is that this advisory report will be a catalyst for funders to invest heavily in much-needed research on social media use and youth mental health. As we learn more about the circumstances under which social media can benefit youth and the circumstances under which it can cause harm, this will facilitate the development of strategies, interventions, and policies to mitigate the associated risks.
Click here to read Dean Dani Fallin’s response to this recent surgeon general advisory.
How has COVID impacted youth mental health?
The COVID era resulted in a number of new stressors for youth. Some youth may have experienced stressors and/or grief because someone in their household or someone with whom they were close got very sick or died. When we went into lockdown, pre-pandemic routines for kids were completely disrupted. Social isolation affected most children and especially adolescents for whom peer groups and relationships are so central to their lives.
When school districts switched to online learning, the adjustment to a new way of learning was stressful for many students and some students experienced significant learning loss. There were also stressors for some students around returning to in-person school amidst the ongoing pandemic after being remote for an extended period of time. Given all of these challenges, it is unsurprising that studies have documented increases in anxiety, depression, and psychological distress among youth since the onset of the pandemic.
Is there anything else that concerns you about youth mental health?
Another issue that concerns me is the insufficient access to mental health care for kids who need it. We know that less than half of those who have a mental health disorder will receive any services from a mental health professional. Among those who initiate services, there is also a very high probability that they will discontinue services after only a few visits and receive so little care there is no opportunity to achieve any clinical benefit. This is extremely frustrating because mental health disorders among youth are treatable. Although there are a number of evidence-based treatments that work well, we have this massive chasm between the potential to help youth that could benefit from mental health services and the percentage of those that receive any (and enough) services to help them on their road to recovery.
What are the biggest threats to mental health treatment?
One major barrier to kids getting the mental health care they need continues to be stigma concerning mental health challenges and mental health treatment. Sometimes this may occur because of stigmatizing attitudes and beliefs held by the child’s caregivers, their extended family members, their neighbors and community, their teachers, or their friends at school.
Other major issues for families who are trying to help their child receive mental health treatment are the mental health workforce shortages and costs of care. The workforce shortages can lead to challenges finding a mental health provider for an intake appointment and long waitlists. Because of the shortage, there is enough demand for mental health providers to set up practices where they don’t have to take any insurance and can operate on a cash-only basis. So, if a family can afford to pay $100 to $150 per therapy session (or $400 to $600 per month for four weekly sessions), they have a chance at finding good care for their child. But for families that rely on health insurance, their options are going to be more limited.
It’s also important to remember that nearly half of kids are insured through Medicaid, and these families are typically limited to seeking care at a mental health clinic that participates in the Medicaid program. Yet, because Medicaid reimbursement rates are so low, it affects the salaries these clinics can offer to providers and they have a difficult time recruiting and retaining qualified providers. To fill the gap, these clinics will recruit therapists with limited experience who recently received their master’s degree and are not yet licensed. The new graduates will work in these settings to get experience, supervision, and training. Once they are fully licensed, they typically leave to set up their own practice. The difference in the salary in the private sector can be in the tens of thousands of dollars [per year], and there is no economic incentive to continue to work in clinics that serve Medicaid-enrolled kids. Many of these therapists will also have college debt that they need to pay off, which further incentivizes the move to the private sector.
Other major challenges for families—especially low-income families—are the logistics of helping their child get to their appointments. This is especially hard when caregivers have inflexible jobs or other childcare responsibilities, lack of reliable transportation, and/or if the clinic is far from where they live.
How is your current research addressing the youth mental crisis?
My research focuses on the implications of recent changes in where and how mental health services are delivered to kids. More specifically, there has been an increase in the delivery of mental health services at school and a dramatic increase in the delivery of services via telemental health to kids, while the delivery of services in the traditional clinic-based setting has fallen. I am studying what these shifts mean for care access and quality, as well as what these shifts mean for mental health care equity.
For example, one of my studies in JAMA Pediatrics found that the percentage of adolescents that received school mental health services increased almost 14 percent between 2018 and 2019. It was especially notable that the increase in school mental health services was most pronounced among non-Hispanic Black adolescents and adolescents from low-income families. Because less than half of youth with a mental health disorder receive any services, an increase in the use of school mental health services likely means that more kids who need help are getting connected to care. This study also provides early evidence that increasing the availability of school mental health services could be a strategy to reduce inequities and access to care among populations that have been historically underserved.
At the onset of the COVID-19 pandemic, there was an immediate and dramatic shift to telemental health services among the child and adolescent population. For example, between 2019 and 2020, where was an 830 percent increase in the number of Medicaid-enrolled kids that received telemental health services. To understand what this means for access to care, I led a study (in press) in which we conducted interviews with therapists that served Medicaid-enrolled kids to get their perspectives on barriers and facilitators of access to telemental health services.
Moving forward, there are so many important questions that we need to answer about school-based mental health and telemental health services. What are the implications for quality of care? Are there specific populations for whom services delivered in school or via telehealth work particularly well? Are there instances when services delivered in these settings may exacerbate inequities in care? My current and future projects will leverage existing databases and collect new data to answer these questions.
What are some things policymakers can do to tackle the youth mental health crisis?
First and foremost, we’re in the midst of a phase of increasing awareness of the importance of youth mental health overall. For example, the publication of the recent advisory reports from the surgeon general on youth mental health is an extremely positive development.
Another strategy is to provide education about youth mental health to those working with our kids in school settings. Many teachers received their training at a time when they didn’t have any course or exposure to topics pertaining to youth mental health. One way to overcome this knowledge gap is for teachers and school staff to participate in mental health literacy training. In North Carolina, the legislature passed a law that mandated all their teachers must have mental health literacy training that covers specific topics. This is a great example of a state that has moved this strategy to the policy realm to expedite mental health literacy training for teachers.
State policymakers and school district leaders can also look for opportunities to invest resources in school mental health services and programs. This can include everything from implementing mental health prevention and promotion programs for all students, such as a social-emotional learning curricula, to the delivery of clinical services at schools for kids based on need.
Additionally, there are approaches state policymakers can implement to improve access to care, especially for Medicaid-enrolled youth. One strategy would be to significantly increase Medicaid reimbursement rates for mental health providers to help address the shortage of providers that serve these kids. To address some of the logistical barriers to care many families face, another strategy would be to extend flexibilities in Medicaid reimbursement policies (most of which were introduced during the pandemic) that continue to allow providers to offer telemental health services to youth.
Janet Cummings, PhD, is a nationally recognized expert on issues pertaining to access and quality of behavioral health care and the role of the safety-net in meeting the needs of underserved populations with mental health and substance use disorders.
