Youth Mental Health

Introduction

Erin Howard, a school counselor in Denver, talks with a student in 2014. Experts say the COVID-19 pandemic, which closed schools for months and left many students feeling isolated, has exacerbated an ongoing mental health crisis among children and teens. The crisis is compounded by a shortage of mental health providers and disparate insurance coverage for mental health services. (Getty Images/The Denver Post/Andy Cross)

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Overview

Last spring, 15 adolescents with serious mental health issues were living in the emergency department at Boston Children's Hospital. They were sleeping in exam rooms at night while waiting for spots to open up in the region's inpatient treatment centers where teens receive individual and group therapy in communal settings. One rainy evening, a 15-year-old girl arrived who had told her pediatrician that she planned a second suicide attempt.

She, too, needed inpatient treatment, a doctor said. But it was taking the hospital about 10 days, on average, to transfer young people to such centers, and for this teen, the wait would be nearly a month. She was kept out of physical danger — the door to her “psych-safe” room in the emergency department was open day and night, any equipment that could be used to harm herself was removed and electronics were forbidden. But she did not receive the mental health care she needed.

“In this process of boarding we broke her worse than ever,” said her mother, who described her daughter as “catatonic” during the emergency department stay. Identified only as G. in a New York Times article to protect her privacy, the teen told the newspaper her room was “padded, insane-asylum-like” and “all you see is walls.”1

A preteen boy concentrates on his smartphone. Some experts say the peer pressure and bullying associated with social media has contributed to childhood depression. (Getty Images/UCG/Universal Images Group/Kurt Wittman)

Her experience is an extreme example of what experts say is a mental health crisis among children and adolescents whose roots are more than a decade old. From 2009 to 2019, the proportion of high school students reporting persistent feelings of sadness or hopelessness grew 40 percent, the percentage who said they were seriously considering suicide rose by more than a third, while the share who said they were creating a suicide plan increased by 44 percent, according to researchers.2

The COVID-19 pandemic intensified the crisis, as kids missed in-person school, dates with friends, sports competitions and time with relatives. Access to mental health care and social services often were disrupted, even as some children lost relatives to the virus or suffered an infection themselves.3

“Anxiety and depression, even in young kids, really increased,” says Dr. Marian Earls, a developmental and behavioral pediatrician in Greensboro, N.C., and chair of the American Academy of Pediatrics' Mental Health Leadership Work Group. While pediatric visits to hospital emergency departments declined overall between 2019 and 2022, the number of visits for self-harm among adolescents increased in all three years and rose in the last two years for those exhibiting mental health symptoms. In a study of 14 states, the number of adolescent suicides rose from an annual average of 836 between 2015 and 2018 to 903 in 2020.4

And while G. had to wait nearly a month for a spot in a residential facility, the situation may be worse elsewhere: Only one in five suicidal teens nationwide are transferred from an emergency room to a mental health facility, research suggests.5

These disturbing trends prompted three professional medical groups representing pediatricians, psychiatrists and children's hospitals last fall to declare a “national emergency in child and adolescent mental health,” and U.S. Surgeon General Vivek Murthy in December issued an advisory to highlight the “urgent need” to address the crisis. “Mental health challenges in children, adolescents and young adults are real and widespread,” he said.6

The underlying causes of the prepandemic deterioration in child and adolescent mental health are not well understood, making it difficult to know exactly how to address the problem. “We need to figure it out, because it is life or death for these kids,” said Candice Odgers, a psychologist at the University of California, Irvine.7

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Researchers have suggested several possible causes, often disagreeing about their relevance or importance. Some say part of the increase in documented mental health symptoms may be due to a greater willingness by young people to talk about mental health concerns. In addition, researchers blame the growing use of social media, increasing academic pressure, shortages in mental health care providers “and broader stressors, such as the 2008 financial crisis, rising income inequality, racism, gun violence and climate change,” according to the surgeon general's advisory.8

Some groups are suffering more than others. Black children are nearly twice as likely to die by suicide than white children, and youth growing up in poverty are two to three times more likely to develop mental health conditions than other young people. During the pandemic, Black youths were more likely to lose a parent or caregiver to COVID-19, Asian-American teens reported greater stress due to pandemic-related bias and harassment, and lower-income adolescents lost access to free school lunches.9

“The school where I work is in a very poor neighborhood that doesn't have that many resources, and our kids have stressful lives to begin with,” says Nell Ross, a clinical social worker in a New York City middle school. “But since in-person school started again in March 2021, it's just a lot worse than before the pandemic.” Some children's parents have died, she explains, and when classes were conducted remotely, students missed a key year of developing social skills.

“I'm seeing a significant increase in depressive symptoms and suicidal ideation, symptoms of PTSD and a lot of anxiety,” says Ross, adding that many kids are being more verbally and physically aggressive.

Ross says she and her fellow social workers at the 450-student school cannot address all the children's needs on site and must refer many for outside help. But stigma can prevent many parents from taking their children to local therapists, who often have long wait lists anyway, says Ross. “Many times our families have to go to a psychiatric emergency room or a hospital just to get to see a therapist in a timely manner.”

The rise in youth mental health problems is coinciding with an acute nationwide shortage of psychologists and psychiatrists, especially in rural areas and minority urban communities. “We're expected to have a shortfall of 120,000 psychiatrists by the year 2030,” says Dr. Rebecca W. Brendel, a psychiatrist and president of the American Psychiatric Association. “The shortage has existed for a long time,” she adds, but is exacerbated by the unprecedented demand for mental health services particularly for youths.

School-based mental health professionals are also in short supply. For instance, about 36,000 school psychologists are working in public schools in the United States, says psychologist Kelly Vaillancourt Strobach, director of policy and advocacy at the National Association of School Psychologists. Another 63,000 are needed to reduce the average number of students per psychologist from 1,162 to the recommended maximum of 500, she says. “This is not a situation where school districts don't value them or aren't hiring them. It's simply we do not have the workforce right now to meet the need.”

Sue-Ann Siegel takes calls in 2020 on a crisis hotline run by Montgomery County, Md. A new three-digit nationwide crisis hotline is scheduled to go live this month. (Getty Images/The Washington Post/Katherine Frey)

As a result, primary care physicians, such as pediatricians and family physicians, are having to fill the gap. But in a recent poll, “Only four in ten parents say their adolescent's primary care providers asks about mental health concerns at all check-ups.”10

Vaillancourt Strobach says the country needs more graduate psychology programs, but “that's a big nut to crack” because such programs are expensive to set up and there are not enough psychologists available to teach. Two partial solutions, she says, would be to create more online graduate programs and make it easier for other mental health professionals such as school social workers and counselors to get a graduate degree by giving them credit for work experience.

Brendel says psychiatry faces a similar problem: not enough residency slots for graduate medical students who want to specialize in the field. A large portion of residency training is funded by a special program in the Department of Health and Human Services. “We would need to increase that funding and reallocate slots from other specialties to psychiatry,” says Brendel.

Boosting mental health services has received renewed attention in Congress in recent weeks after several mass shootings, including one by a teen gunman at an elementary school in Uvalde, Texas. In a rare show of cooperation, Democrats and Republicans in the Senate and House passed the Bipartisan Safer Communities Act, and President Biden signed it into law on June 25. In addition to bolstering measures to address gun violence, the legislation would boost spending on mental health services.11

Earlier this year, Biden requested billions of dollars for fiscal 2023 to improve mental health care, including scholarships and loan repayment for students preparing to become mental health providers who commit to practice in regions with the greatest unmet needs. His budget request also seeks increased funding for schools to hire more mental health staff and would double funding to help primary care physicians integrate mental health providers into their practices. The president also proposes strengthening parity in insurance coverage between mental and physical health by requiring insurers to reduce patient cost-sharing for mental health care and to maintain an adequate network of behavioral health providers.12

“If we don't fund the building of a mental health infrastructure within this country, then we are not going to have the resources we need,” says Brendel.

As advocates, clinicians, researchers and lawmakers consider how to deal with the mental health crisis among children and teens, here are some of the questions they are debating:

Is social media a major contributor to the surge in child and adolescent mental health problems?

Last September, The Wall Street Journal published an article headlined “Facebook Knows Instagram Is Toxic for Teen Girls, Company Documents Show,” the second installment of a 17-part investigation of the company, which owns Instagram.13 The series was based on leaked documents from a then-anonymous former Facebook employee, who later stepped forward to testify before Congress.

“The choices being made inside of Facebook are disastrous for our children, for our public safety, for privacy and for our democracy,” whistleblower Frances Haugen told lawmakers in October. In one leaked company survey, 13.5 percent of U.K. teen girls said Instagram worsens their suicidal thoughts. Another company study found 17 percent of teen girls reported their eating disorders worsened after using the social media platform.14

In media interviews and online, Facebook defended itself. Neil Potts, its vice president for trust and security, told NPR the majority of survey respondents in its teen research said Facebook and Instagram “have a net positive on their mental health.”15

The controversy comes at a time of growing concern that social media — such as Facebook, YouTube, Instagram, Snapchat, TikTok and others that allow users to network and share content — is a major contributor to plummeting mental health among teens.

“A sudden increase in the rates of depression, anxiety and self-harm was seen in adolescents — particularly girls — in the United States and the United Kingdom around 2012 or 2013,” said Jonathan Haidt, a social psychologist at New York University and co-author of the bestseller The Coddling of the American Mind: How Good Intentions and Bad Ideas Are Setting Up a Generation for Failure. “Only one suspect was in the right place at the right time to account for this sudden change: social media.”16

For example, the share of U.S. teens diagnosed with a “major depressive episode” hovered between 8.0 and 8.3 percent for five years before jumping to 9.1 percent in 2012 and steadily climbing to 14.4 percent in 2018, according to a government survey. There was no similar-sized increase in adults over age 26.17 During the same six-year period, the share of teens who used social media multiple times a day climbed from 34 percent to 70 percent, according to a Common Sense Media survey.18

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“All this points to how our social media usage has become a public health crisis,” said Helen Lee Bouygues, who heads the Paris-based Reboot Foundation, which conducts polls and supports research that promotes critical thinking. Governments should implement “warning labels and age restrictions” on social media use, she said.19

But correlation does not imply causation, says psychologist Mitchell J. Prinstein, the chief science officer at the American Psychological Association. While concerned about deteriorating mental health among children and adolescents, Prinstein cautions against casually assuming that rising social media use must be an important factor.

Another Common Sense Media survey found teen social media use continued to climb between 2018 and 2020, “almost entirely among those who are currently displaying symptoms of depression.” But the organization warned that its surveys cannot be used to establish causation and that two scenarios are equally likely: Teens on social media experienced greater levels of depression or teens with depression increasingly turned to social media for help, such as to find health care information and like-minded communities.20

As for Facebook's leaked teen surveys, they too are a poor starting point for drawing any conclusions about cause and effect, according to Laurence Steinberg, an expert on adolescence and professor of psychology and neuroscience at Temple University. Self-reports are unreliable, Steinberg said, and the surveys did not include a comparison group of teens who did not use Instagram, “which would be crucial to drawing any inferences about the effects of Instagram use.”21

Academic researchers have studied the potential impact of social media use on teen mental health, but the results of such research are decidedly mixed. NYU's Haidt helps maintain an open-source online document that lists and discusses dozens of conflicting studies.22

Nevertheless, Haidt is convinced of the culpability of social media, and he cites several experimental studies designed to show causality. They randomly assigned individuals to either continue using social media or substantially reduce social media use. “After a few weeks, people who reduce their use generally report an improvement in mood or reduction in loneliness or symptoms of depression,” said Haidt.23

But Christopher J. Ferguson, a professor of psychology at Stetson University in DeLand, Fla., says such randomized studies are problematic. Study participants “will be able to figure out the hypothesis if they watch the news: ‘Oh, you want to see if I'm going to be happier after I stopped using social media.’” And then, consciously or unconsciously, participants will respond in the way they think they are supposed to, he says.

Ferguson is the lead author of a meta-analysis of 33 studies with differing methodologies that concluded “time spent on social media is a very poor predictor of mental health symptoms of any kind,” he says. More important might be how social media is used and by whom, he adds.

Prinstein agrees. Using social media to keep up with the news, find new friends, reduce isolation, connect with supportive communities and engage in social movements could have benefits, he says. But visiting sites that encourage competitive comparisons, promote self-harm or expose kids to discrimination could negatively affect some teens' mental health, he adds, especially if they are already psychologically vulnerable. One or two studies of varying quality exist to support each possibility, “but we can't draw firm conclusions based on one or two studies,” he says.

“This is a woefully underfunded area of research,” Prinstein says. He praises Biden for requesting $5 million to fund research into the impact of social media use on teen mental health in his FY 2023 budget but calls it a “minimal amount.”24

Is teaching schoolkids about mental health effective?

Speaking at a February Senate hearing about the country's mental health crisis, Claire Rhyneer described “a difficult and dark period of depression” she experienced a few years earlier.

“I was self-harming, and all I felt was uncertainty,” said Rhyneer, a 2021 high school graduate from Anchorage, Alaska. “Mental health was never discussed at school, at home, or even in my health classes, besides the ‘take care of yourself, get sleep, eat well, and exercise’ spiel.”

Rhyneer eventually found help in her community, but many youths do not, she said. “They doubt and diminish their experience,” she said. “They're scared to reach out. They're worried what their community will say.” Rhyneer told lawmakers schools must teach students about mental health.25

However, studies are mixed on how effective such instruction is at increasing knowledge, reducing stigma and changing behavior — and for how long.

Rylan Hagan, a model sixth grader and basketball player at Perry Street Prep in Washington, D.C., killed himself in 2018 at age 11. He was one of a growing number of children under 18 who have taken their own lives in recent years. (Getty Images/The Washington Post/Evelyn Hockstein)

Since 2016, at least 10 states have passed laws requiring schools to teach mental health. Maine, New Jersey and New York require such instruction in kindergarten through grade 12. Virginia requires it in grades nine and 10. In Florida, sixth through 12th graders must learn about mental health. California, Connecticut, Nevada, Oklahoma and Vermont have passed similar laws.26

Typically, each school district decides on its mental health curriculum. “That's just a reflection of how education occurs in our country,” says psychologist Sharon Hoover, co-director of the National Center for School Mental Health at the University of Maryland School of Medicine. “It's very locally driven.”

Social worker Ross' middle school in New York City conducts morning lessons on different mental health disorders. “Our kids definitely know words like ADHD, autism, depression and suicidality,” she says, “so they then can talk about those things if they relate and also recognize symptoms and advocate for their friends.”

While mental health education in schools has two goals — to reduce stigma and increase mental health literacy — its ultimate goal is to have young people, armed with this knowledge, ask for help if they need it, says John Richter, director of public policy at the Mental Health Association in Albany, N.Y., an advocacy and training organization that was instrumental in getting New York's law passed in 2016. It became effective in 2018.

Mental illnesses often first appear at about age 14, and even younger for anxiety disorders, says Richter. Only about 40 percent of people with a diagnosable mental health disorder ever get help, he says, and it typically takes 10 years to get diagnosed after first experiencing symptoms. “We want to close that gap,” he says.

Researchers have studied mental health education programs abroad as well as programs in the United States that existed in some districts even before current laws were passed.

“There was moderate evidence to show that there is improvement in mental health literacy and also in reducing stigma,” says psychologist Anne-Marie Burn of the University of Cambridge in the United Kingdom, who helped conduct a review of randomized controlled studies of mental health literacy programs for children and teens.27 But there was no way to know if the improvements were sustained, because few studies had long-term follow-up, says co-author and psychologist Joanna Anderson. “It is possible that it was just the effect of the intervention being fresh, and that could wear off over time,” she says.

Spanish researchers reviewed some of the same studies as Burn and Anderson, along with others, and found improved mental health literacy but no significant reduction in stigma. They also concluded that students who participate in mental health literacy programs do not seek counseling or support, if needed, more readily than students who do not participate. “In general, no significant improvements were found in [help-seeking], neither post-intervention, nor at 6 months,” the researchers wrote.28

Experts caution that it is difficult to study the impact of mental health education on help-seeking behavior because there can be a significant lag. “You would have to do a longitudinal analysis, and most studies don't really do that, and if they do do a follow-up, it's [at] about six months, not longer,” says psychologist Nicole Eberhart, a senior behavioral scientist at the RAND Corporation, a research organization in Santa Monica, Calif.

But even if future research were to show that mental health education leads students with mental health needs to seek help, it may not be available, either from school-based therapists or from providers in the community, especially in poor and minority communities.29

Nevertheless, it is important to give kids this knowledge, says Ross, and Hoover says mental health education in schools can help establish the urgent need for more mental health providers. Richter says the curriculum should address the lack of access head on and let kids know that “you're liable to run into long waiting lists, that you need to be persistent, that you need to see your primary care doctor … while you continue to try to get an appointment with a psychiatrist or social worker.”

Meanwhile, states may offer school districts guidance in implementing mental health education, including best practices, but they often do not provide oversight to ensure it is being done effectively. That occurred in New York, the first state to require mental health education in schools.

In April, New York State Comptroller Thomas P. DiNapoli issued a report showing that of 22 school districts it surveyed about their mental health curricula, three could not provide any written documentation. Among the rest, the curricula varied widely, and the comptroller called on the state to step in.

“Without some level of oversight, the [State Education] Department cannot be assured that students are receiving mental health education or that the instruction achieves the intent of the Law: to enhance student understanding, attitudes, and behaviors that promote health, well-being, and human dignity,” the report said.30

Do treatments for anxiety and depression in youths work?

Anxiety and depression are some of the most common mental health disorders in children and adolescents. The available treatments are psychotherapy or medication or some combination of the two. But the evidence for their effectiveness in reducing symptoms or bringing these disorders into remission is sometimes unclear.

“There is an active debate in the research field about both psychological and pharmacological treatments for depression and anxiety,” says Zachary Cohen, a clinical psychology researcher at UCLA's Anxiety and Depression Research Center. “And it is important that we get better information about how effective they are and for whom they are effective.”

The American Academy of Child & Adolescent Psychiatry (AACAP) publishes treatment guidelines for families and physicians.31 “For children and adolescents who are presenting with depressive symptoms, we most typically recommend psychotherapy first,” says Dr. Stephanie Hartselle, a clinical associate professor at Brown University who practices pediatric and adult psychiatry in Providence, R.I. That can include cognitive behavioral therapy, dialectical behavioral therapy and interpersonal therapy, say experts. For anxiety, cognitive behavioral therapy that also exposes kids to the situations that trigger their anxiety is often the first-choice treatment, she says.

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Nevertheless, research shows that these “gold standard” therapies do not work for everyone and for all conditions. Psychological therapies work best when treating anxiety disorders but are disappointing for treating depression, according to a meta-analysis of 447 studies led by Harvard University psychologist John R. Weisz.32

“We're still looking for ways to improve psychotherapy for depression,” says Prinstein of the American Psychological Association. Nevertheless, it is better than no therapy at all, he says.

Sometimes, medication needs to be added to the treatment regimen, says Hartselle, who considers starting medication simultaneously with psychotherapy for those who, for example, are having intense suicidal thoughts or are harming themselves. “The medication tends to lower the intensity of symptoms so that they can engage in their therapy,” she says.

But too many kids may be receiving only drugs. “We have a huge mental health workforce shortage,” says Prinstein. So, families and primary care physicians “are going to have to make decisions about treatment based on factors other than what the data might show because there are problems with access,” he says.

In addition, not just any therapist will do. “For specific things like phobias, obsessive compulsive disorder, severe anxiety and severe depression, you really need someone who has the skills and has been trained in the evidence-based [psychological] treatments, because it can go very wrong,” says Hartselle. “And it is terrifying.” Too many therapists who advertise themselves as experts do not meet these requirements, she says.

The most vulnerable children may be particularly at risk of not receiving the full spectrum of mental health treatment and of being overmedicated. Children who are in foster care, are involved in the juvenile justice system, have experienced trauma or have developmental problems often receive drugs “prior to or instead of first-line, psychological treatments,” according to a 2018 study.33

The study also said most evidence supporting the use of drugs for depression and anxiety among youths is of “very-low-to-low quality.”34

A systematic review of dozens of studies for treatment of depression, published in 2020, came to a similar conclusion.35

“There are several reasons for the low strength of the evidence, but a primary driver is the small number and sample size of available studies,” says Meera Viswanathan, the study's lead author and director of the RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center. “Doing research in children and adolescents is challenging under the best of circumstances,” she notes, “and vulnerable populations, such as children or adolescents with depression, need greater protections.”

The studies in the review that showed drugs benefit kids with depression reported significantly reduced symptoms, but few studies showed that children or adolescents go into remission, she said. “When studies examine remission, they generally focus on the short-term, 12 to 24 weeks, rather than on long-term remission,” she said.

In fact, there are few long-term studies of medication use for the treatment of depression in youth. “People prescribed these drugs usually take them for months or years. It's ridiculous that a drug is approved based on trials that last, let's say, six, eight or 10 weeks, because … efficacy wanes with time,” says Michael Hengartner, a senior lecturer and applied psychology researcher at Zurich University of Applied Sciences in Switzerland. Long-term studies are expensive, however, and pharmaceutical companies will not undertake them as long as regulators accept short-term trials, he says. Drug agencies should require long-term controlled studies comparing drugs to a placebo or other treatment, “but they don't. And that's a problem,” he says.

It is not the only problem with studies of anti-depressants. Physicians and researchers depend on peer-reviewed journal articles to assess whether a drug is effective and safe, but their assessment will be accurate only if the outcomes of all trials — negative, as well as positive — are published. A recent study found that of 30 trials of four anti-depressants, 15 showed negative results. But six of these were not published in medical journals, and two were misrepresented as positive.36

“Nothing less than full transparency should be considered acceptable in the realm of healthcare,” said the researchers. “Greater awareness of reporting bias is needed among researchers and clinicians so that they do not naively accept published research findings at face value.”37

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Background

Miniature Adults

Before the late 1800s, medical literature rarely mentioned the emotional and behavioral disorders of children. Children were regarded “as miniature adults, to be introduced to adult economic responsibilities as early as possible,” wrote the late British psychologist William Parry-Jones.38

Dr. Benjamin Rush, considered America's first psychiatrist, did not mention children in his influential textbook Medical Inquiries and Observations upon the Diseases of the Mind, published in 1812. In the first 45 years of the American Journal of Insanity (1844–1889), the forerunner of the American Journal of Psychiatry, not one article referred to children.39

In the last quarter of the 19th century, the status of children began to change. Reformers pressed states to expand public education so more children could attend school and lobbied legislatures to ban and limit child labor.40 Childhood was beginning to be thought of as distinct from adulthood, and there was “a growing awareness of the psychological component of childhood, with interest in individual differences and in the deterministic significance of early life experience,” said Parry-Jones.41

By the end of the 19th century, most psychiatric textbooks included sections on children. But juvenile mental illness was thought to be rare and occur mostly after puberty once the brain was more developed. “How soon can a child go mad? Obviously not before it has got some mind to go wrong,” wrote British psychiatrist Henry Maudsley in his 1895 textbook The Pathology of Mind. 42

One possible explanation for this approach is that psychiatrists did not have much professional experience with children. Psychiatry originated in public mental hospitals, welfare-like institutions mostly for adults whose numbers were growing in the second half of the 19th century. Psychiatrists at the time were public employees, and the institutional setting in which they worked molded and shaped psychiatric thought and practice, said historian Gerald N. Grob.43

At the turn of the century, mental illness was often thought to be the result of heredity or organic factors, such as head injury and infections, and psychological factors such as grief and fright.44

20th Century Advances

In the early 20th century, the measurement and understanding of children's mental health advanced.

G. Stanley Hall, considered the founder of the field of psychology in the United States, was instrumental in developing the psychological questionnaire. Hall's patient questionnaires covered “topics as diverse as fears and dreams,” according to the International Association for Child and Adolescent Psychiatry and Allied Professions. “Many other questionnaires were subsequently developed to measure specific symptoms” of conditions such as depression and hyperactivity.45

Hall also was instrumental in establishing the field of developmental psychology, which explores how children change over time. His book, Adolescence, Its Psychology and its Relations to Physiology, Anthropology, Sociology, Sex, Crime, Religion, and Education, published in 1904, “focused attention on the role of physical growth, the biologic changes of puberty, brain development, genetic influences, sleep and biological rhythms, physical health, social transitions, religious, educational, and cultural influences,” according to a research article.46

Swiss psychologist Jean Piaget revolutionized developmental psychology, a field that expanded after World War I, but some criticized his theories for underestimating the role of social and cultural influences. (AFP/Getty Images/Staff)

The field of developmental psychology expanded after World War I, in particular with the work of Swiss psychologist Jean Piaget, who theorized that children go through four stages of biologically driven cognitive development as they mature. His ideas “revolutionised developmental psychology,” but were not without critics, according to the International Association for Child and Adolescent Psychiatry and Allied Professions. Piaget's research involved only a small group of children and thus was “subject to bias,” and it “underestimated the importance of social and cultural influences” on child development, the international organization said.

Around the same time, lawyers, physicians, social workers and philanthropists sought to move the treatment and prevention of juvenile delinquency, considered a form of mental illness, from the courts to communities. Between 1922 to 1927, The Commonwealth Fund, a private foundation in New York, established eight child guidance clinics across the country.47

“Care teams of psychiatrists, psychologists, and social workers tested children for mental, emotional, or behavioral problems; examined their home environments; and created tailored treatment plans,” according to a fund history. “Clinics worked with local juvenile courts, schools, and children's agencies to identify those deemed ‘predelinquent’ — often impoverished children with chaotic home lives.” Within a decade, the number of clinics grew to 230.48

However, the initial promise of child guidance clinics faltered. Children with a variety of problems were lumped together as “maladjusted” and offered psychotherapy that was often open-ended and lengthy, according to the International Association for Child and Adolescent Psychiatry and Allied Professions. Pediatricians rarely worked in the clinics, which were typically isolated from mainstream medical, academic and research institutions. In addition, therapists often blamed parents for their children's mental health problems.49

Today's nonprofit child guidance clinics, funded by states and charitable donations, have evolved and increasingly use evidence-based therapies.50

New Therapies

In the 1960s, Aaron Beck, considered one of world's most influential psychotherapists, was working with depressed patients at the University of Pennsylvania. Beck found that his patients often expressed spontaneous, negative thoughts, which he helped them to evaluate and change.

“He also worked with them to address underlying maladaptive beliefs about themselves, others, the world, and the future,” according to the Beck Institute in Bala Cynwyd, Pa., which educates the public about Beck's methods. This therapy became known as Cognitive Behavior Therapy, or CBT, and is now widely recommended for treating anxiety and depression.51 (See box with definitions.)

Prozac, a selective serotonin reuptake inhibitor, became available in the 1980s to treat depression and, later, anxiety disorders and other mental health issues. (Getty Images/Stephen Chernin)

Since the 1950s the mental health field has seen a revolution in the development and use of pharmacological treatments. For example, in the 1950s the FDA approved methylphenidate for use in children with “hyperkinetic disorder,” known today as attention-deficit/hyperactivity disorder (ADHD), and psychiatrists began using chlorpromazine in people with psychosis. In 1970, the FDA approved the use of lithium for treating mania, referred to today as bipolar disorder, and in the 1980s, a new generation of antipsychotics with fewer side effects than earlier drugs came into use to treat schizophrenia. During the same decade, selective serotonin reuptake inhibitors, such as fluoxetine whose brand name is Prozac, became available to treat depression and eventually anxiety disorders.52

From the 1950s through the 1970s, clinicians viewed mental health as inseparable from people's socialization, relationships and life events and conceptualized mental illness in broad terms such as “psychoses,” “neuroses” and “nerves,” according to sociologist Allan V. Horwitz. That changed in the 1980s, after the American Psychiatric Association published the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM). The third edition contained nearly 300 separate diagnoses and clearcut symptom lists, nearly triple those in the first edition.53

The first edition in 1952 had barely mentioned mental disorders among children and adolescents, and the second edition expanded childhood diagnoses only slightly. But the DSM-III “greatly accelerated the enlargement of diagnoses among youth,” said Horwitz, devoting 65 pages to this category of mental illness, compared to three pages in the DSM-II. “The following two revisions continued to broaden this class, especially for attention deficit/hyperactivity disorder, autism, and Asperger, a condition that first appeared in the DSM-IV,” he added.54

There are three views, not necessarily mutually exclusive, of the third and later editions of the DSM, according to Horwitz. It can be seen as the embodiment of the field's scientific progress, a stigmatizing collection of labels thrust on patients or the result of cultural forces and professional disagreements.55

But the DSM's influence is not in doubt. It establishes which psychiatric conditions and their treatments are taught in medical school, reimbursed by insurance companies and researched in academia. And it shapes how individuals, including youth, think about their mental health.56 Since the 1990s, the powerful pharmaceutical industry has helped to push DSM diagnoses into the public consciousness, said Horwitz.

“In addition to massive advertising campaigns, they generously funded advocacy groups concerned with childhood and adolescent conditions,” he wrote.57

As prescriptions for antidepressants increased, the FDA became concerned about potential side effects in young people. In 2004, the FDA required a “black-box” warning, the highest safety warning that the agency can assign a medication, on the labels of all classes of antidepressants, saying that children and adolescents taking the drugs were at increased risk of suicidal thinking and behavior. Since then, researchers have debated whether the black box warning is justified and based in sound science.58

Government Measures

As soldiers returned home after World War II, the federal government recognized the sometimes disabling mental health problems many experienced as a result of their service. In 1946, President Harry Truman signed the National Mental Health Act, which led to the creation three years later of the National Institute of Mental Health, which funds research on improving the understanding and treatment of mental illness.59 Since then, the federal government has sponsored research, issued reports and passed laws in an effort to further improve the understanding and treatment of mental illness.

In 1963, President John F. Kennedy signed into law the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which established a system of federally funded community mental health centers. (The term “retardation” was common at the time but is now understood to be pejorative and is no longer used in professional circles.) Three years later, Congress expanded their role to include serving children. However, a shortage of mental health professionals and the Vietnam War's diversion of funding slowed creation of the clinics.

After signing legislation in 1963 establishing a system of federally funded community mental health centers, President John F. Kennedy gives the pen to his sister Eunice Shriver, who lobbied heavily for the legislation. Congress later expanded the system to include children, but a shortage of mental health professionals plagued the program. (Getty Images/Bettmann/Contributor)

In 1967, the National Institute of Mental Health created the Center for Studies of Suicide Prevention, with clinical psychologist Edwin Shneidman at its helm. The next year, Shneidman founded the American Association of Suicidology, which developed a certification program for suicide crisis centers. It certified its first center in 1976.

In 1980, President Jimmy Carter signed the Mental Health Systems Act, which reaffirmed the role of community mental health centers and created performance standards for them. The following year, President Ronald Reagan convinced Congress to repeal the act and significantly reduce federal funding to states for mental health care. This was in accord with the financial goals of the conservative Reagan administration to reduce federal spending and social programs and transfer responsibility of many government functions to states, according to sociologist Alexander R. Thomas.60

In 1992, Congress authorized the Comprehensive Community Mental Health Services for Children and Their Families Program, which provided funds to coordinate the often-fragmented systems that serve children with serious emotional disturbances. Family advocates and representatives from schools, mental health services, the courts and other services would work in teams to plan and implement individualized services for each child's needs.61

Meanwhile, employers and insurance companies tried to rein in health care costs, which were rising due to an aging population, expensive new drugs and advances in technology such as sophisticated imaging machines. One target was mental health care. In response, President Bill Clinton signed the Mental Health Parity Act of 1996, which restricted the ability of group health insurance plans to place lower dollar caps on mental health benefits than on medical and surgical benefits. However, plans could still have higher copayments for mental health care and stricter limits on the number of inpatient days or outpatient visits.62

In 2004, the National Institute of Mental Health released initial results from its clinical trial on treatments for adolescent depression. The 12-week study found a combination of the medication fluoxetine — at the time, the only antidepressant approved by the FDA for use in children and adolescents — and cognitive behavioral therapy to be the most effective treatment.63

In 2005, the federal government launched the National Suicide Prevention Lifeline, which currently connects callers to the closest of more than 200 local crisis centers across the country, 24 hours a day, seven days a week.64

Concerned that insurance coverage for mental health remained unfair, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Like the 1996 law, it applied only to group plans, exempted plans sponsored by small employers and allowed plans to drop mental health coverage. But it also expanded parity by including deductibles, copayments, out-of-pocket expenses, co-insurance, covered hospital days and covered outpatient visits.65

In 2010, the Patient Protection and Affordable Care Act — known as Obamacare — applied federal mental health parity laws to insurance plans purchased by individuals and small companies through online insurance exchanges.66

As the COVID-19 pandemic intensified the mental health needs of children and adolescents, Congress allocated about $190 billion to K-12 schools in 2020 and 2021, through three relief bills: the Coronavirus Aid, Relief, and Economic Security Act, the Coronavirus Response and Relief Supplemental Appropriations and the American Rescue Plan Act of 2021.

In addition to investing in distance learning technology and emergency response planning and supporting students who fell behind in learning, school districts across the country are using the money to hire mental health professionals. According to the White House, these funds have allowed schools to increase the number of social workers by 65 percent and the number of school counselors by 17 percent, as of March.67

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Current Situation

Federal Efforts

Biden is making mental health a priority. “Let's take on mental health — especially among our children, whose lives and education have been turned upside down,” said Biden in his State of the Union message on March 1.68

The White House issued a fact sheet laying out the president's strategy. It includes awarding $225 million to train and expand the number of community health workers in underserved communities and plans to develop a national certification program for peer mental health workers (people who have experienced mental illness).

Four weeks later, Biden released his proposed fiscal 2023 budget, which included the following requests:

• $700 million for existing programs that provide training, access to scholarships and loan repayment for students training to be mental health clinicians who commit to practice in underserved communities.

• Making permanent Certified Community Behavioral Health Clinics, a demonstration project that delivers mental health and substance use care to people regardless of their ability to pay.

• $1 billion to help schools hire additional counselors, social workers, school psychologists and other health workers.

• Nearly $700 million to staff and support local mental health crisis centers so that they can properly respond to calls coming into the National Suicide Prevention Lifeline.69

“The administration's comprehensive and wide-ranging plan, if enacted, will help psychiatrists and our partners and communities heal our nation,” Dr. Saul Levin, CEO and medical director of the American Psychiatric Association, said in statement.70

More funding needs to be targeted at youth, says Amy Wimpey Knight, president of the Children's Hospital Association in Lenexa, Kansas, which represents more than 220 children's hospitals. “We have almost 75 million kids in this country that are under the age of 18, and that's almost a quarter of our population,” says Knight.

The association is backing the Strengthen Kids' Mental Health Now Act, a bill sponsored by 27 Democrats and 2 Republicans introduced in the House in March that would, among other things, increase Medicaid payment for pediatric behavioral health services, help states expand pediatric mental health services using telehealth and invest in inpatient psychiatric care for youth and recruitment of pediatric mental health professionals.

“Medicaid, while not great for mental health services, is better than commercial insurance in many ways, but it's still far from sufficient in order to keep providers in the business of seeing these kids,” says Knight. The bill has been referred to the House Committee on Energy and Commerce.71

Meanwhile, on June 25 Biden signed the Bipartisan Safer Communities Act, a gun violence bill, in the wake of several mass shootings, including one at an elementary school in Uvalde, Texas, in which a teenage gunman killed 19 students and 2 teachers.72

Mourners attend a vigil May 29 for victims of the school shooting in Uvalde, Texas, in which an 18-year-old gunman killed 19 students and two adults. The killings prompted a national discussion on gun control and teen mental health and led to more federal funding for treating mental health problems among youths. (Getty Images/Xinhua News Agency/Wu Xiaoling)

“I don't believe in doing nothing in the face of what we saw in Uvalde and we've seen in far too many communities,” said Sen. John Cornyn, R-Texas, one of the key negotiators shepherding the act through Congress. “Doing nothing is an abdication of our responsibility as representatives of the American people.”

The law increases funding for school security initiatives, expands criminal background checks for some gun buyers, prevents a larger group of domestic violence offenders from purchasing firearms and invests in programs that allow local authorities to seize guns from troubled individuals. In addition, it authorizes $15 billion to be invested in community behavioral health centers, in-school mental health programs and telehealth services for people in crisis and in need of counseling, among other mental health programs.73

The National Alliance on Mental Illness, a grassroots mental health organization in Arlington, Va., supports the law. “The Bipartisan Safer Communities Act will expand mental health resources in schools and increase the availability of mental health care across the country,” the alliance said in a statement. However, it cautioned against conflating mental illness with gun violence. “People with mental illness are far more likely to be victims of violence than perpetrators, and pointing to mental illness as the cause of gun violence perpetuates discrimination and stigma that discourages people from seeking help.”74

National Suicide Prevention Lifeline

Reaching the National Suicide Prevention Lifeline (800-273-TALK) is about to get easier. Starting on July 16, individuals will need to use only three digits, 988, to be connected via call, text or chat with a trained counselor at a local mental health crisis center. Use of the lifeline is expected to climb.

Creating the shorter number is only a first step in transforming the lifeline. The government expects local crisis centers to train and hire more staff to meet demand. Eventually, the government hopes to build a crisis response system so that operators at all crisis centers can not only counsel people but refer them to community mental health providers, including mobile crisis teams and stabilizations centers.75

But it will take additional funding to reach those goals. Already, the system cannot keep up with demand. Last year, roughly 17 percent of the approximately 2 million calls to the lifeline were abandoned before a counselor answered, according to a New York Times analysis. In interviews, callers blamed long hold times.76

Valerie, a 24-year-old in Burlington, N.C., said she has found it increasingly difficult to get through to a counselor, and several times she hung up and harmed herself. “If you are in crisis, you need help immediately,” she told the newspaper.77

Getting referrals to services could be even more difficult.

“Right now, the full system we need to have in place to respond to people in crisis who call 988 is not available in most communities,” according to the National Alliance on Mental Illness. Additional mental health crisis services “are only available in some communities — and often at insufficient levels to meet the demand.”78

According to a June RAND Corporation survey of public health officials, only 48 percent of respondents' jurisdictions had a “short-term crisis stabilization program and only 28 percent possessed urgent care units for mental health.” In addition, only 22 percent of jurisdictions had crisis call centers or hotlines that were equipped to schedule intake and outpatient appointments for individuals in need.79

The lifeline's national operations are federally funded, but crisis call centers, mostly nonprofits, historically get a maximum of only $5,000 in federal stipends. They must raise the bulk of the money for their operations on their own. In anticipation of a rapid increase in demand once the 988 is rolled out, the Biden administration last December sent $282 million to call centers and is requesting more than twice that much in its fiscal 2023 budget.80

President Donald J. Trump signed the legislation that established 988 in October 2020, which gave state lawmakers permission to raise money for crisis call centers by imposing a monthly fee on phone bills. Similar state fees that fund the national emergency 911 number raise about $3 billion annually.81

But, according to the National Alliance on Mental Illness, only four states — Colorado, Nevada, Virginia and Washington — have authorized a 988 fee. Such legislation is pending in California, Michigan, New Jersey and Rhode Island.82

Opponents have argued that a fee, often between 10 and 20 cents per month, would be a burden for poor people, while proponents say properly funded call centers would save taxpayers money by reducing the use of police in mental health emergencies.83

State Efforts

State legislatures have been busy this year passing laws to address children's mental health. At least 14 states have enacted 26 bills related to children's mental health in schools, according to the National Conference of State Legislatures.

For instance:

• Alabama passed a law requiring local boards of education and independent school systems to employ a mental health service coordinator.

• Florida now requires that students referred to a community or school-based mental health service provider be assessed within 15 days.

• New Jersey's School Report Card, which the Department of Education issues annually and contains statistical profiles of every public school, must now include the number of health professionals at each school.

• Utah is developing a behavioral health curriculum for students in public schools, and

• Washington state is requiring schools to excuse absences due to mental health problems.84

Several other states have bills pending, the National Conference of State Legislatures says. For example, Illinois, Pennsylvania and Rhode Island have proposed requiring that mental health be taught in schools. If passed, those laws would bring the total number of states requiring mental health education in schools to at least 13.

In a December poll by the National Alliance on Mental Illness, 87 recent of parents supported mental health education in schools.85

Former Facebook employee and whistleblower Frances Haugen tells a Senate committee on Oct. 5, 2021, that the company knew its social media platforms, including Instagram and Facebook, were “disastrous for our children,” but chose profits over safety. The company has disputed Haugen's statements. (Getty Images/Jabin Botsford)

To address the shortage of psychiatrists, including child psychiatrists, six states — Florida, Hawaii, Nebraska, New York, Vermont and Washington — have introduced legislation to allow psychologists to prescribe medication for mental health disorders, according to the conference. Currently, Idaho, Illinois, Iowa, Louisiana and New Mexico allow psychologists who undergo additional pharmacological training to prescribe medication.86

The issue is divisive. (See Pro/Con.) The American Psychological Association supports such legislation, saying the current state of affairs is unsafe. Unlike psychologists, primary care physicians, who do most of the prescribing of medications for mental disorders, “have not received extensive training in the diagnosis and treatment of mental health disorders,” says the American Psychological Association's website.87

Psychiatric organizations oppose allowing psychologists — who have Ph.Ds but not medical degrees — to prescribe medication.

“Mental illness and psychotropic medications affect not only the developing brain but all organ systems,” says the website of the American Academy of Child & Adolescent Psychiatry. “Child and adolescent psychiatrists obtain a four-year medical education with a focus on anatomy, physiology, and pharmacology. During the subsequent five years of residency training, child and adolescent psychiatrists receive extensive clinical supervision in evidence-based treatments and management of medications and side effects.”88

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Outlook

Therapist Shortages

To bring the crisis in youth mental health under control, experts agree, additional government investment will be needed over the next decade in research and in the mental health workforce and infrastructure.

“The pediatric health community has rallied together to make youth mental health our top priority, and Congress has heard us,” says Knight of the Children's Hospital Association. She says she expects Congress in the next few years to pass bipartisan legislation that would include “better reimbursement and investment in the pediatric workforce and mental health programs and services across the continuum of care.”

“I am waiting and hoping for a Mental Health Moonshot,” says Prinstein of the American Psychological Association, “and there is no reason why we should not add $1 billion to fund more research on child mental health.” Without it, he adds, it is unclear how much treatment options for children with mental illnesses will progress.

“It's possible we will have better treatments in the next five to 10 years since we have innovations and creative uses of technologically assisted services all of the time,” he adds. “But research on mental health treatment is woefully underfunded.”

UCLA researcher Cohen says he is not anticipating a new miracle drug for depression in the next decade, but that current drugs could be put to better use through personalized medicine rather than the current trial and error approach. Researchers are studying how to identify markers that would allow physicians to make such predictions.89

“If we can predict which of the existing treatments will result in the best outcome for a specific individual,” Cohen says, “we can make significant progress using treatments that are already available.”

Questions likely will remain about the long-term safety and efficacy of existing drugs, says Hengartner of the Zurich University of Applied Sciences, who sees no incentive for pharmaceutical companies to conduct long-term studies. “Their major objective is to bring drugs into the market and to get approval for new indications,” he says. “As long as they can get this with very short-term studies, they won't conduct long-term studies.”

Brown University's Hartselle sees potential in some newer treatment approaches currently available only for those ages 18 and older. For example, she says, she hopes pediatric studies on transcranial magnetic stimulation, or TMS, will lead to government approval of its use in youth within the next 10 years.

“TMS is a nonmedication-based treatment where the brain is targeted with some magnetic pulses, and we have seen dramatic improvement in adults with that treatment for depression and even OCD,” says Hartselle, referring to obsessive compulsive disorder. She also has seen robust results in adults from IV treatment with the anesthetic ketamine for suicidality — defined as suicidal thoughts, plans or attempts — and severe depression. “And I know that they are working on potentially being able to approve that for adolescents and potentially children. I hope that's coming down the pike.”

Ideally, drug treatment is coupled with psychotherapy, but access will continue to be a problem in the next decade unless universities start graduating more therapists, says Hartselle. Prinstein agrees. “We need to direct funds to universities where doctoral students in clinical, counseling, and school psychology are trained,” he says. Even if government investment in graduate psychology education increased a hundredfold, he adds, “it would still be about 1/7th of the investment that the U.S. dedicates to physical health.”

The University of Maryland's Hoover says schools will remain one of the best places to provide mental health services to children, including providing them with mental health education to reduce stigma and improve literacy.

“Given the trend we have seen of more and more states requiring mental health education in schools,” she says, “I am hopeful that we are likely to see that trend continue” over the next several years.

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Pro/Con

Should psychologists be allowed to prescribe medication for mental health problems?

Pro Alicia Plemmons Assistant Professor of Economics, Southern Illinois University Edwardsville, and Research Affiliate, Knee Center for the Study of Occupational Regulation, West Virginia University. Written for CQ Researcher, July 2022 One in four Americans suffers from a diagnosable behavioral health issue each year, yet 60 percent of counties in the United States — overwhelmingly in rural or socioeconomically disadvantaged areas — do not have a single licensed psychiatrist. This shortage is compounded for children and adolescents, because fewer providers specialize in providing care for minors. Patients in these shortage areas who need medication have few options. For example: If they live in a state that allows primary care providers to prescribe mental health medication, they can see a provider — but the clinician may not have experience in treating these conditions. They can travel to a county with a psychiatrist, which is cost-prohibitive for many people, who often must take time off from work or school to make the trip. Alternatively, in 45 states, patients can forgo medication and see a psychologist, but talk therapy may have limited effectiveness if the patient is not receiving care needed for preventable chemical imbalances. The argument for granting psychologists prescriptive authority is not a question of replacing psychiatrists but of providing resources for adults and adolescents in areas without access to such services. Expanded prescriptive authority for psychologists has been shown to reduce suicides, increase the number of psychology practices in counties with shortages of mental health care, and does not cause measurable increases in the number of reported poor mental health days in the local community. The primary concern about maintaining limited psychologist scope of practice is the quality and safety of prescribing behavior. Expanding psychologists' prescriptive authority can be targeted and systematic, requiring advanced, specialized training in psychopharmacology, education requirements from the American Psychological Association and mandatory clinical rotation hours. Multiple additional levels of checks exist before medication reaches a patient. First, prescribing practitioners are subject to state-specific reporting requirements in all 50 states and the District of Columbia under the Prescription Drug Monitoring Program, which monitors for prescription abuse. Second, pharmacists review and may deny filling a prescription if the medication is inappropriate for a patient, serving as a secondary review. Increasing access to mental and behavioral health resources can be done safely, as we have seen in Illinois, Indiana, Iowa, Louisiana and New Mexico — the five states that allow psychologists to prescribe medication under rigorous training conditions. Expanding prescriptive authority can save the lives of adolescents and adults experiencing distress or crisis.

Con M.D., M.P.A Saul Levin CEO and Medical Director, American Psychiatric Association. Written for CQ Researcher, July 2022 After two years of stress, uncertainty and grief caused by the COVID-19 pandemic, demand for mental health care services is extremely high. Expanding access to mental health care to meet demand is one of our most critical and persistent challenges. To expand access to care, we must use evidence-based approaches that put patient safety first. Some mistakenly believe that access to mental health care services will be expanded if we allow professionals such as psychologists — who are not medical doctors — to prescribe psychiatric drugs. Because psychologists do not have the education and training to medically diagnose, Medicare will not reimburse them for writing such prescriptions. Unsafe interactions can occur when medication is not prescribed by a trained physician. Although psychologists provide valuable and much-needed mental health services, they are not trained to prescribe powerful psychiatric medications. Psychiatrists are the only medical doctors who have specialized in mental health and have four years of medical school and residency specifically tailored to treat complex mental health issues with medication and other therapy. This specialized training is extremely important because psychiatric drugs do not affect just the mind, but can also affect a person's heart, liver, kidneys and other vital organs. Many patients also take medications for nonmental health conditions, which can interact poorly with psychiatric drugs if treatment is not carefully monitored by a skilled psychiatrist. In extreme cases, the consequences can be fatal. Our minds and bodies are inextricably linked, and there can be no health without mental health. Thus, expanding access to care requires an integrated care team working together for the patient's total health, including mental health. The Collaborative Care Model is such an approach, and its effectiveness has been supported by robust evidence. Under the model, primary care physicians collaborate with a psychiatric consultant to prescribe appropriate treatment, including medications, and measure the patient's progress. This patient-centered team approach improves access, is less expensive and more convenient and maintains the quality and safety of patient care. Expanding access to medication does not necessarily increase access to care or support the mental health of Americans, since medication is usually not the sole remedy for mental or physical health concerns. To increase access and protect patient safety, we must enact policies that promote care coordination and ensure that medication is only administered under the supervision of a trained medical doctor.

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Discussion Questions

Here are some issues to consider regarding today's mental health crisis among the nation's children and teens:

• Experts are unsure what is causing the crisis, with some blaming the rise of social media while others blame the pandemic or the shortage of mental health practitioners. Still others say it is due to worries about social problems, such as rising gun violence, climate change and racism. What do you think is the major cause?

• Black children are nearly twice as likely to die by suicide than white children, and young people growing up in poverty are two to three times more likely to develop mental health conditions than other youths. How can these trends be changed?

• Do you think mental health issues should be discussed in K-12 health classes?

• Experts predict a shortfall of 120,000 psychiatrists in the United States by 2030. The Biden administration has proposed several solutions, including providing scholarships and loan repayment for students training to be mental health clinicians who commit to practice in regions with the greatest unmet needs. The president also wants to increase funds for schools to hire mental health staff and for primary care physicians to integrate mental health providers into their practices and strengthen parity in insurance coverage for mental and physical health. Will these measures help increase the supply of psychiatrists?

• Given the shortage of psychiatrists, who are the only ones — along with other medical doctors — who can legally prescribe medication for mental health conditions, five states recently authorized psychologists to prescribe such drugs. Do you think that is a good idea?

• A recent federal report found that many health plans and insurance companies are not abiding by laws requiring them to cover treatment for mental health and substance use disorders on a par with their coverage for medical and surgical conditions. What do you think should be done about this?

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Short Features

Mental Health Parity Continues to Fall Short

Max Tillitt, who had struggled with addiction and mental health disorders for years, was making progress when his insurance company cut off coverage for his treatment at a residential facility.

The 21-year-old had become addicted to opioid painkillers prescribed for a football injury during high school, The Washington Post reported. He later became addicted to heroin and suffered repeated relapses, all while struggling with bipolar disorder, depression and a sleep disorder.

In 2015 he was being treated at the Beauterre Recovery Institute, a residential facility near Minneapolis, where doctors said he needed 45 days of treatment. But Tillitt's insurance company, United Behavioral Health, said he needed — and the company would only cover — 21 days of treatment. Beauterre discharged him. Tillitt died from an overdose more than two months later.

His mother, DeeDee Tillitt, noted that United paid the full cost — $9,221 — for emergency room efforts to revive Max. “They had to because it's medical,” she said. “There was nothing they could deny. That [money] could have paid for his goddamn treatment and saved his life.”1

The website for Beauterre Recovery Institute in Owatonna, Minn., advertises a “whole-person approach” to treating addiction, but insurance companies sometimes refuse to cover all of the treatment prescribed for patients. Without adequate treatment, many people relapse, and some die from overdoses. (Beauterre Recovery Institute/Screenshot)

Health plans and insurance companies are not meeting legal requirements that they cover treatment for mental health and substance use disorders on a par with their coverage for medical and surgical conditions, according to a January report from the U.S. Department of Health and Human Services (HHS) and the departments of the Treasury and Labor.

“Access to mental and behavioral health support is critical as the COVID-19 pandemic continues to impact so many lives across the country,” said HHS Secretary Xavier Becerra. “We are committed to working with our federal partners to … hold health plans and insurance companies accountable for delivering more comprehensive care.”2

The report found that one large insurance plan did not cover prescriptions for substance use disorder, and two covered nutritional counseling for medical conditions such as diabetes but not for eating disorders. Another health plan required prior authorization for all outpatient services for mental health and substance use disorders but required such authorization only for a “select list” of medical and surgical outpatient services. These are just a few examples of 36 different types of violations the government found. The report did not name the companies.3

“As a person in recovery, I know firsthand how important access to mental health and substance use disorder treatment is,” Secretary of Labor Marty Walsh, who vowed to enforce mental health parity laws, said in a prepared statement.4 (Walsh is recovering from alcohol use disorder.)

AHIP, an association of health insurers, did not respond to CQ Researcher's repeated requests for an interview. The Association for Behavioral Health and Wellness, a narrower trade organization whose members manage behavioral health insurance benefits, agrees with the government's examples of violations.

“We agree that those are mental health parity violations, and generally our members recommend that their customers remove those types of exclusions from their products and services,” says Deepti Loharikar, who until mid-May was the senior director of regulatory affairs for the association. “Enforcement is generally appropriate where insurers are continuing to apply the prohibitive exclusions.”

The Mental Health Parity and Addiction Equity Act of 2008 said that insurers and health plans must treat mental health and substance use disorder benefits on an equal footing with medical and surgical benefits. That means financial requirements, such as coinsurance and copays, and treatment limitations, such as preauthorization and visit limits, cannot be more restrictive for mental health and substance use disorder benefits. But regulators lacked a way to track violations unless consumers complained.

In December 2020, Congress enacted the Consolidated Appropriations Act, 2021, which gave the mental health parity law some teeth. It required health insurers and health plans to compare their treatment limits for mental health and substance use disorder benefits to their limits for medical and surgical benefits, and to turn the analyses over to the government upon request.5

In 2021, the Employee Benefits Security Administration within the Labor Department sent 156 letters to insurance plans and issuers asking for these comparative analyses. None of the initial responses contained sufficient information, despite guidance from the department about how to conduct the analyses, the January report said. But there was enough information for regulators to conclude that substantive violations exist in coverage of mental health and substance use disorders.6

States have also begun ramping up enforcement of mental health parity laws, says David Lloyd, senior policy adviser at The Kennedy Forum, which advocates for mental health parity. “I think the pandemic had something to do with both state and federal efforts,” he says. “Also, there has been very robust advocacy from groups like The Kennedy Forum, the American Psychiatric Association and Mental Health America chapters.” (Mental Health America is a grassroots group addressing the needs of people living with mental illness.)

States have primary enforcement authority over health insurance policies sold to individuals and employers by companies located within their borders. The U.S. Department of Labor regulates “self-funded” health benefit plans of large corporations, in which companies create and fund their own health plans, usually managed by an insurance company, as an alternative to purchasing a plan from an insurer.

In New York, for example, the New York State Office of the Attorney General and the U.S. Department of Labor announced last August that UnitedHealthcare and two subsidiaries had been fined more than $15.6 million to settle claims that the company had engaged in two practices that violated state and federal mental health parity laws. One was to discount the reimbursement of out-of-network psychologists and master's-level mental health clinicians much more heavily than the reimbursement of out-of-network general medical care. Another was to use algorithms in a discriminatory way to deny claims for outpatient mental health care.7

Currently, only states can levy fines for violations of mental health parity laws. But that may change. The Labor Department has asked Congress for authority to levy civil monetary penalties for parity violations to “incentivize compliance.” Mental health advocacy groups support that recommendation.8

“In the absence of real consequences for not complying with the law, we're seeing a real lag in insurance motivation and ability to do that,” says Dr. Rebecca W. Brendel, a psychiatrist and president of the American Psychiatric Association.

The insurance industry opposes the idea of federal fines. “We would, of course, not be in favor of that,” says Loharikar.

Meanwhile, the Biden administration has asked Congress to require insurance companies to improve their network of mental health providers. If plan members cannot find in-network providers, mental health parity does not mean much, say experts. A 2019 study found that behavioral health providers were more than five times as likely as other providers to be outside an insurance network and are paid less, according to Bloomberg Law.9

“When a health plan doesn't have enough cardiologists or pulmonologists, it will offer higher reimbursement to attract out-of-network providers to come in network,” says Lloyd. “Plans should be increasing reimbursement in order to attract behavioral health providers.”

However, Loharikar says, “We have heard anecdotally that increasing their pay does not entice [mental health providers] to join an insurance network.” There are more than enough patients who are willing to pay mental health providers out-of-pocket, she says, so they do not need to join health insurance networks and take on all the resulting administrative work of filing claims.

“There just aren't enough behavioral health providers out there, and figuring out how to increase the workforce is integral to solving this problem,” she says, adding it is a problem that insurers cannot solve alone.

Meanwhile, Tillitt's parents have sued United in a class action that some say could be a landmark case for mental health parity. A judge ruled in the Tillitts' favor in 2019, but a three-judge panel of the Ninth Circuit Court of Appeals reversed the decision in March. The Tillitts have appealed the case for a hearing by a full panel of judges.10

— Barbara Mantel

[1] Lenny Bernstein, “Equal mental health insurance coverage elusive despite legal guarantee,” The Washington Post, June 2, 2022, https://tinyurl.com/bdfe6pwe.

[2] “U.S. Departments of Labor, Health and Human Services, Treasury Issue 2022 Mental Health Parity and Addiction Equity Act Report to Congress,” news release, HHS.gov, Jan. 25, 2022, https://tinyurl.com/ywmff6mk.

[3] “2022 MHPAEA Report to Congress,” Department of Labor, Department of Health and Human Services and Department of the Treasury, Jan. 25, 2022, pp. 5, 21-23, https://tinyurl.com/k7vcjwhj.

[4] “US Departments of Labor, Health and Human Services, Treasury Issue 2022 Mental Health Parity and Addiction Equity Act Report to Congress,” op. cit.; Ana Marie Cox, “Having someone with alcoholism in the Cabinet reminds us that recovery is never over,” The Washington Post, March 24, 2021, https://tinyurl.com/4f2x5aum.

[5] “FAQS About Mental Health and Substance Use Disorder Parity Implementation and the Consolidated Appropriations Act, 2021 Part 45,” The U.S. Department of Labor, April 2, 2021, pp. 1-2, https://tinyurl.com/48pptkae.

[6] “2022 MHPAEA Report to Congress,” op. cit.

[7] Gary Enos, “Large settlement with insurer signals federal emphasis on enforcing parity,” Mental Health Weekly, Aug. 20, 2021, https://tinyurl.com/3wnhepes.

[8] “2022 MHPAEA Report to Congress,” op. cit., p. 52.

[9] “FACT SHEET: President Biden to Announce Strategy to Address Our National Mental Health Crisis, As Part of Unity Agenda in his First State of the Union,” The White House, March 1, 2022, https://tinyurl.com/nj56k4jp; Alex Ruoff, “Biden's Call for Mental Health Coverage Sparks Legislative Push,” Bloomberg Law, March 15, 2022, https://tinyurl.com/58vyzehx.

[10] Bernstein, op. cit.

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Pediatricians, Family Physicians Try to Fill Gaps in Care

With 91 percent of U.S. counties experiencing a severe shortage of child and adolescent psychiatrists, according to the American Academy of Child & Adolescent Psychiatry, mental health care for young people increasingly is falling to primary care physicians, such as pediatricians and family practice doctors.11

“To meet the needs of children, pediatricians need to take on a larger role in addressing mental health problems,” according to a 2019 report from the American Academy of Pediatrics. “Yet, the majority of pediatricians do not feel prepared to do so.” Many say treating mental health problems is outside of their scope of expertise, involves more time than they can spare and requires specialized training that they lack.12

Medical organizations and the federal government are employing several strategies to help primary care pediatricians and family physicians better address the mental health needs of young people.

Nonprofits, such as Project ECHO, are helping to provide mental health services in rural areas, which are in dire need of providers. Through this project, primary care physicians participate in virtual sessions with medical specialists at large academic medical institutions to learn how to treat complex medical conditions, including mental illness. (Robert Wood Johnson Foundation/Screenshot)

“They should be able to manage mild-to-moderate anxiety, depression, ADHD [attention-deficit/hyperactivity disorder] and substance use in their patients,” says Dr. Marian Earls, a developmental and behavioral pediatrician in Greensboro, N.C., and chair of the Mental Health Leadership Work Group of the American Academy of Pediatrics. “And primary care clinicians should be co-managing with mental health professionals when kids need specialty care.”

One approach is to better train primary care physicians in mental health, starting with their graduate medical school education, says Earls. Some innovative residency programs are including mental health professionals in many of the clinics that pediatric residents rotate through, which can range from pediatric cardiology, neurology and emergency medicine to adolescent medicine.

“Residents are starting to learn about working as a team with mental health professionals,” Earls says.

For practicing pediatricians, the academy offers a mental health toolkit designed to help physicians, among other things, set up their practices to offer mental health services, address psychiatric emergencies, screen young patients for behavior and mental health problems and understand medication options.13

Nonprofits and the federal government are also trying to help. For example, some states have tapped Medicare funds to support a nonprofit endeavor called Project ECHO. Under the project, primary care physicians can participate in weekly virtual sessions with medical specialists at large academic medical institutions to gain the expertise they need to treat complex medical conditions, including mental illness. The initiative has 175 hubs offering mentoring to physicians across 46 states.14

Some primary care physicians are integrating a mental health professional — such as a licensed clinical social worker, a child and family therapist or a psychiatric nurse practitioner — into their practices. “The role of this person is more as a consultant than a therapist,” says Earls. They can help administer screening tools for depression or anxiety; participate in the morning huddle with the practice doctors to discuss the needs of kids coming for appointments that day; do brief 15- to 30-minute interventions with patients and their families; coordinate with teachers and school guidance counselors and refer patients to a therapist and, if necessary, a psychiatrist.

But primary care practices face obstacles in establishing this kind of model, says Earls. Mental health professionals are in short supply and insurers' reimbursement practices, which vary from state to state, are complicated, Earls says.

“Some payers won't pay for someone to see the doctor and the mental health professional in the same visit,” she says. “What's the logic in that? We have families that have to take off from work to bring their kid to the practice, and they can't afford to be coming back.” And in some states, Medicaid and commercial insurers will not reimburse for a mental health professional's brief intervention at a primary care practice.

Another approach, known as collaborative care, has a mental health professional integrated into the primary care practice who reviews cases weekly with a consulting psychiatrist on contract with the practice. They discuss the appropriate diagnosis, what type of psychotherapy might be needed, possible online patient resources, whether a safety plan needs to be put in place, whether the primary doctor should prescribe medication and the patient's progress, says Dr. Megan Chiarelli, a child and adolescent psychiatrist in Mission Hills, Calif., who has worked as a collaborative care psychiatrist.

“Estimates are that in just half a day a week, a psychiatrist could assist in providing care to a panel of 50 to 70 patients, as opposed to some single-digit number of patients that an individual psychiatrist might be able to see during that period of time alone,” says Dr. Rebecca W. Brendel, a psychiatrist and president of the American Psychiatric Association.

Collaborative care works, according to dozens of controlled trials for people with depression and anxiety. “Consistently, this approach resulted in better outcomes than primary care or specialty care alone,” said Dr. Thomas Insel, a psychiatrist and neuroscientist who led the national Institute of Mental Health for 13 years and who has advocated for collaborative care for years. In January 2017, Medicare and Medicaid approved paying for collaborative care, and commercial insurers followed suit.15

“All the minutes that are spent in the care of this patient for their behavioral health needs, either by the embedded behavioral health specialist in the practice or by the psychiatrist, are totaled together,” and the primary care practice uses special codes to bill the insurer, says Chiarelli. The practice then pays the psychiatrist a fee.

But Earls says that while collaborative care may work for adults, it is not sufficient for pediatrics. Pediatricians see a broad selection of children with mental health problems, many of whom may not require the care of a psychiatrist, she says. Practices serve “those who have risk, those with emerging symptoms, those with functional concerns but not a diagnosis,” says Earls.

“In addition, there is an expectation that the practice have a contract with a psychiatrist for using the [billing] codes,” she says. “Given the very small number of child and adolescent psychiatrists, this is unlikely to have broad application.”

— Barbara Mantel

[11] “Child and Adolescent Psychiatrist (CAP) Workforce Distribution Map, 2022,” American Academy of Child & Adolescent Psychiatry, 2022, https://tinyurl.com/3byfe75x.

[12] Cori M. Green et al., “Achieving the Pediatric Mental Health Competencies,” Pediatrics, Nov. 1, 2019, https://tinyurl.com/4yazhykb.

[13] Marian F. Earls, Jane Meschan Foy and Cori M. Green, “Addressing Mental Health Concerns in Pediatrics: A Practical Resource Toolkit for Clinicians, 2nd edition,” American Academy of Pediatrics, undated, https://tinyurl.com/muenys3u.

[14] “Project ECHO connects specialists with on-the-ground practitioners to bridge health gaps in rural communities,” Robert Wood Johnson Foundation, undated, https://tinyurl.com/83kma3x8; Greg Howe, Allison Hamblin and Lauren Moran, “Financing Project ECHO: Options for State Medicaid Programs,” Center for Health Care Strategies, Inc., September 2017, https://tinyurl.com/4d3zbnx8.

[15] Thomas Insel, Healing: Our Path from Mental Illness to Mental Health (2022), pp. 111–112.

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Bibliography

Books

Horwitz, Allan V., DSM: A History of Psychiatry's Bible, Johns Hopkins University Press, 2021. A sociology professor at Rutgers University analyzes the impact of the Diagnostic and Statistical Manual of Mental Disorders on the perspective and understanding of mental health in the United States.

Insel, Thomas, Healing: Our Path from Mental Illness to Mental Health, Penguin Press, 2022. A former director of the National Institute of Mental Health offers solutions for families and society in addressing the barriers that prevent progress on mental health.

Articles

Eder, Steve, “As a Crisis Hotline Grows, So Do Fears It Won't Be Ready,” The New York Times, March 17, 2022, https://tinyurl.com/yc77xxak. The National Suicide Prevention Line plans to expand its services but is already struggling to meet current demand.

Firozi, Paulina, “In a devastating pandemic, teens are ‘more alone than ever.’ Many struggle to find help,” The Washington Post, Dec. 19, 2021, https://tinyurl.com/yc7tcufp. The pandemic has increased feelings of isolation and exacerbated mental health challenges among the nation's youth.

Richtel, Matt, “Hundreds of Suicidal Teens Sleep in Emergency Rooms. Every Night,” The New York Times, May 8, 2022, https://tinyurl.com/4t29rzuy. A shortage of inpatient psychiatric services has left suicidal teens waiting desperately for treatment and help.

Solomon, Andrew, “The Mystifying Rise of Child Suicide,” The New Yorker, April 4, 2022, https://tinyurl.com/ykeb2a6w. An expert in psychology uses a family tragedy to emphasize the mental health emergency that is contributing to rising child suicide rates.

Steinberg, Laurence, “Does Instagram Harm Girls? No One Actually Knows,” The New York Times, Oct. 10, 2021, https://tinyurl.com/4tadw3za. A professor of psychology at Temple University highlights the lack of research on whether exposure to social media has affected the psychological well-being of girls.

Wells, Georgia, Jeff Horwitz and Deepa Seetharaman, “Facebook Knows Instagram Is Toxic for Teen Girls, Company Documents Show,” The Wall Street Journal, Sept. 14, 2021, https://tinyurl.com/ynwcu8jk. Technology reporters say internal Facebook research shows its Instagram social media platform harms teen girls' mental health.

Reports and Studies

“Addressing The Youth Mental Health Crisis: The Urgent Need For More Education, Services, And Supports,” Mental Health America, 2020, https://tinyurl.com/4th3rpkp. A mental health advocacy group suggests solutions to address the nation's youth mental health challenges.

“Protecting Youth Mental Health: The U.S. Surgeon General's Advisory,” U.S. Department of Health and Human Services, 2021, https://tinyurl.com/yrycny5t. A government report outlines various measures individuals and groups can take to protect the mental health of children and teens.

Amado-Rodriguez, Isaac Daniel, et al., “Effectiveness of Mental Health Literacy Programs in Primary and Secondary Schools: A Systematic Review with Meta-Analysis,” Children, March 31, 2022, https://tinyurl.com/mu3kmnjc. A group of academics say research shows limited benefit from mental health education in schools.

Cantor, Jonathan H., et al., “Preparedness for 988 Throughout the United States: The New Mental Health Emergency Hotline,” RAND Corporation, 2022, https://tinyurl.com/yckbuzhz. Many state and local agencies are not prepared to meet the increased demand for mental health services expected when the new three-digit emergency mental health crisis line goes into effect in July.

Kei Yan Ma, Karen, Joanna K. Anderson and Anne-Marie Burn, “Review: School-based interventions to improve mental health literacy and reduce mental health stigma — a systematic review,” Child and Adolescent Mental Health, Jan. 10, 2022, https://tinyurl.com/3xby686c. This review examines the effectiveness of school-based interventions in improving mental health literacy and combating stigmas surrounding mental health issues.

Lebrun-Harris, Lydie A., et al., “Five-Year Trends in US Children's Health and Well-being, 2016–2020,” JAMA Pediatrics, March 14, 2022, https://tinyurl.com/5n8xuryb. A group of academics analyze measures aimed at addressing children's mental health and identify trends in 2019 and 2020 that may correspond with the COVID-19 pandemic.

Rideout, Victoria, et al., “Coping with COVID-19: How Young People Use Digital Media to Manage Their Mental Health,” Common Sense Media, 2021, https://tinyurl.com/2p8y37js. A national survey documents how technology affected the well-being of young people during the pandemic.

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The Next Step

COVID-19

Adams, Katie, “Telehealth visits for mental health continue to rise despite dropping in every other specialty,” MedCityNews, June 23, 2022, https://tinyurl.com/4dca52mf. Telehealth utilization for mental health patients continues to climb, even as the pandemic abates. Other specialties are seeing fewer telehealth visits.

MacDonald, Logan, “New Colorado survey shows COVID-19 youth mental health effects with an increase in depression,” KKTV, June 15, 2022, https://tinyurl.com/z5zrmrvv. A Colorado survey found mental health issues worsened among children compared to before the COVID-19 pandemic.

Smith, Erin, et al., “The economic and societal effects of COVID-19 on our brains,” Brookings Institution, June 23, 2022, https://tinyurl.com/5cu78sd8. Recent research suggests one-third of COVID-19 sufferers will have new or recurrent psychiatric problems in the ensuing year.

Government Action

Bocanegra, Michelle, “‘What happened to the beds?’: AG James hosts hearing confronting mental health crisis in New York,” Gothamist, June 22, 2022, https://tinyurl.com/5xwp465x. A 2014 decision to slash the number of beds in mental health facilities in New York in favor of investing in preventative measures has prevented children from getting treatment.

Corrigan, James, “DOJ: Maine unnecessarily segregates children with mental health, developmental disabilities,” WMTW, June 22, 2022, https://tinyurl.com/5avk6p4b. The U.S. Department of Justice found that Maine violates the Americans with Disabilities Act by segregating children with mental health issues into psychiatric hospitals and juvenile detention facilities.

Schnell, Mychael, “House passes package addressing mental health, 20 Republicans vote ‘no’,” The Hill, June 22, 2022, https://tinyurl.com/4ydz2hts. A bill that would create a federal Behavioral Health Crisis Coordinating Office and reauthorize millions of dollars for mental health services was passed overwhelmingly in the House.

Parity

“City, county step up mental health coverage,” Insurance News Net, June 21, 2022, https://tinyurl.com/bdz8573c. Local officials in Pima County, Ariz., and the city of Tucson have adopted federal mental health parity requirements, improving insurance coverage for city and county employees.

Bernstein Lenny, “Equal mental health insurance coverage elusive despite legal guarantee,” The Washington Post, June 2, 2022, https://tinyurl.com/bdfe6pwe. Enforcement of mental health parity has become a top priority for the Labor Department, as it adds enforcement staff and seeks the power to impose civil penalties on noncompliant insurers.

Freed, Meredith, Juliette Cubanski and Tricia Neuman, “FAQs on Mental Health and Substance Use Disorder Coverage in Medicare,” KFF (Kaiser Family Foundation), June 6, 2022, https://tinyurl.com/2s39p9dw. Medicare, which provides health insurance for older Americans and children with disabilities, has rules requiring mental health parity.

Social Media

“TikTok and social media can distort mental health information for teens,” KSLTV, May 27, 2022, https://tinyurl.com/yh8679pj. Some teens self-diagnose themselves with mental health conditions they do not have after watching informational videos on TikTok.

Manavis, Sarah, “Social media isn't always bad for children, it depends how they use it,” The New Statesman, June 22, 2022, https://tinyurl.com/48s5v7a4. How teens use social media may be more important to their mental health than how often they use it.

Romero, Tracey, “Even a short break from social media can improve your mental health,” Philly Voice, June 2, 2022, https://tinyurl.com/yck5vw3t. A recent study found that a one-week break from social media can significantly improve anxiety and depression.

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Contacts

American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Ave., N.W., Washington, DC 20016
202-966-7300
aacap.org
A membership organization that promotes the healthy development of youth and families through advocacy, education and research.

American Psychiatric Association
800 Maine Ave., S.W., Suite 900, Washington, DC 20024
202-559-3900
psychiatry.org
A membership organization that promotes access to mental health care and advocates for the profession.

American Psychological Association
750 First St., N.E., Washington, DC 20002
800-374-2721
apa.org
A scientific and professional organization representing psychologists.

Children's Hospital Association
16011 College Blvd., Suite 250, Lenexa, KS 66219
913-262-1436
childrenshospitals.org
A membership organization that represents more than 220 children's hospitals around the United States.

Mental Health America
500 Montgomery St., Suite 820, Alexandria, VA 22314
703-684-7722
mhanational.org
A community-based nonprofit advocating for people living with mental illness.

National Alliance on Mental Illness
4301 Wilson Blvd., Suite 300, Arlington, VA 22203
703-524-7600
nami.org
A grassroots organization advocating for Americans affected by mental illness.

National Association of School Psychologists
4340 East West Highway, Suite 402, Bethesda, MD 20814
301-657-0270
nasponline.org
A professional association working to improve students' learning, behavior and mental health.

RAND Corporation
P.O. Box 2138, 1776 Main St., Santa Monica, CA 90407
310-393-0411
rand.org
A research organization that develops solutions to public policy challenges, including mental health.

Substance Abuse and Mental Health Services Administration
5600 Fishers Lane, Rockville, MD 20857
877-726-4727
usa.gov/federal-agencies/substance-abuse-and-mental-health-services-administration
A branch of the Department of Health and Human Services charged with improving the quality and availability of services for those suffering from mental illnesses or substance use disorders.

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Footnotes

[1] Matt Richtel, “Hundreds of Suicidal Teens Sleep in Emergency Rooms. Every Night,” The New York Times, May 8, 2022, https://tinyurl.com/2p82m7zx.

[2] “U.S. Surgeon General Issues Advisory on Youth Mental Health Crisis Further Exposed by COVID-19 Pandemic,” news release, U.S. Surgeon General, Dec. 7, 2021, p. 8, https://tinyurl.com/2yemhn9s.

[3] Ibid., p. 9.

[4] Lakshmi Radhakrishnan et al., “Pediatric Emergency Department Visits Before and During the COVID-19 Pandemic — United States, January 2019-January 2022,” Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, Feb. 25, 2022, pgs. 313, 315-318, https://tinyurl.com/2bffyv72; Marie-Laure Charpignon et al., “Evaluation of Suicides Among US Adolescents During the COVID-19 Pandemic,” JAMA Pediatrics, April 25, 2022, https://tinyurl.com/mra7mfpn.

[5] Andrew Solomon, “The Mystifying Rise of Child Suicide,” The New Yorker, April 4, 2022, p. 31, https://tinyurl.com/ycrdsujs.

[6] “AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health,” American Academy of Pediatrics, Oct. 19, 2021, https://tinyurl.com/2s3px89y; “Protecting Youth Mental Health: The U.S. Surgeon General's Advisory,” news release, U.S. Surgeon General, Dec. 7, 2021, https://tinyurl.com/2yemhn9s and “U.S. Surgeon General Issues Advisory on Youth Mental Health Crisis Further Exposed by COVID-19 Pandemic,” op. cit.

[7] Matt Richtel, “‘It's Life or Death’: The Mental Health Crisis Among U.S. Teens,” The New York Times, May 3, 2022, https://tinyurl.com/eatn2tfc.

[8] “Protecting Youth Mental Health: The U.S. Surgeon General's Advisory,” U.S. Department of Health and Human Services, Dec. 7, 2021, p. 8, https://tinyurl.com/ymnavr8z.

[9] Ibid., pgs. 8, 11.

[10] “Mott Poll Report: Parent Views on Addressing Mental Health Concerns in Adolescents,” C.S. Mott Children's Hospital, University of Michigan Health, March 21, 2022, https://tinyurl.com/9588sbut.

[11] Emily Cochrane, “Congress Passes Bipartisan Gun Legislation, Clearing It for Biden,” The New York Times, June 24, 2022, https://tinyurl.com/bdvh32ac.

[12] “FACT SHEET: President Biden to Announce Strategy to Address Our National Mental Health Crisis, As Part of Unity Agenda in his First State of the Union,” The White House, March 1, 2022, https://tinyurl.com/mv2w9y4h.

[13] Georgia Wells, Jeff Horwitz and Deepa Seetharaman, “Facebook Knows Instagram Is Toxic for Teen Girls, Company Documents Show,” The Wall Street Journal, Sept. 14, 2021, https://tinyurl.com/36ht6xbw.

[14] Vanessa Romo, “Whistleblower's testimony has resurfaced Facebook's Instagram problem,” NPR, Oct. 5, 2021, https://tinyurl.com/5c9n9ar2.

[15] Ibid.

[16] Jonathan Haidt, “Digital technology under scrutiny: a guilty verdict,” Nature, Feb. 13, 2020, p. 226, https://tinyurl.com/43vutzu3.

[17] “Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health,” Tables A.27B and A.28B, Substance Abuse and Mental Health Services Administration, 2021, https://tinyurl.com/2p8s3jr3.

[18] “Social Media, Social Life: Teens Reveal Their Experiences,” Common Sense Media, 2018, p. 8, https://tinyurl.com/bdz8ruah.

[19] Helen Lee Bouygues, “Social Media Is a Public Health Crisis. Let's Treat It Like One,” U.S. News & World Report, July 20, 2021, https://tinyurl.com/2s42z9zr.

[20] Victoria Rideout et al., “Coping with COVID-19: How Young People Use Digital Media to Manage Their Mental Health,” Common Sense Media, 2021, pgs. 1, 25–26, 30, https://tinyurl.com/2p8djtdp.

[21] Laurence Steinberg, “Does Instagram Harm Girls? No One Actually Knows,” The New York Times, Oct. 10, 2021, https://tinyurl.com/2bymddm2.

[22] Jonathan Haidt and Jean Twenge, “Social Media and Mental Health: A Collaborative Review,” unpublished manuscript, https://tinyurl.com/4jzbpyfb.

[23] Haidt, op. cit.; Jonathan Haidt, “Teen Mental Health Is Plummeting, and Social Media Is a Major Contributing Cause,” Senate Judiciary Committee, May 4, 2022, p. 9, https://tinyurl.com/77mkpmfu.

[24] “FACT SHEET,” op. cit.

[25] Claire Rhyneer, “Testimony of Claire Rhyneer,” U.S. Senate Committee on Health, Education, Labor & Pensions, Feb. 1, 2022, https://tinyurl.com/yncu3723.

[26] “Addressing The Youth Mental Health Crisis: The Urgent Need For More Education, Services, And Supports,” Mental Health America, Appendix C, pp. 36–38, https://tinyurl.com/6t2sesse.

[27] Karen Kei Yan Ma, Joanna K. Anderson and Anne-Marie Burn, “Review: School-based interventions to improve mental health literacy and reduce mental health stigma — a systematic review,” Child and Adolescent Mental Health, Jan. 10, 2022, https://tinyurl.com/5f43a4za.

[28] Isaac Daniel Amado-Rodriguez et al., “Effectiveness of Mental Health Literacy Programs in Primary and Secondary Schools: A Systematic Review with Meta-Analysis,” Children, March 31, 2022, pgs. 5–7, 11, https://tinyurl.com/25yum2yz.

[29] “Supporting Child and Student Social, Emotional, Behavioral, and Mental Health Needs,” U.S. Department of Education, Oct. 20, 2021, p. 5, https://tinyurl.com/36sb2nxm.

[30] Andrea C. Miller et al., “Oversight of Mental Health Education in Schools: State Education Department,” Office of the New York State Comptroller, April 11, 2022, pp. 9–10, https://tinyurl.com/3dweyrtx.

[31] “Depression: Parents' Medication Guide,” American Academy of Child & Adolescent Psychiatry, 2018, https://tinyurl.com/4f2jm35c; “Anxiety Disorders: Parents' Medication Guide,” American Academy of Child & Adolescent Psychiatry, 2020, https://tinyurl.com/2ve4aysp.

[32] John R. Weisz et al., “What Five Decades of Research Tells Us About the Effects of Youth Psychological Therapy: A Multilevel Meta-Analysis and Implications for Science and Practice,” American Psychologist, Feb-March, 2017, https://tinyurl.com/ypmsh8y4.

[33] Jennifer L. McLaren, “Psychotropic medications for highly vulnerable children,” Expert Opinion on Pharmacotherapy, March 2018, https://tinyurl.com/567unfff.

[34] Ibid.

[35] Meera Viswanathan et al., “Treatment of Depression in Children and Adolescents: A Systematic Review,” Agency for Healthcare Research and Quality, April 2020, https://tinyurl.com/y6uc6apb.

[36] Erick H. Turner et al., “Selective publication of antidepressant trials and its influence on apparent efficacy: Updated comparisons and meta-analyses of newer versus older trials,” PLOS Medicine, Jan. 19, 2022, p. 2, https://tinyurl.com/2s4bf7jx.

[37] Ibid.

[38] Joseph M. Rey et al., “History of Child Psychiatry,” in IACAPAP Textbook of Child Adolescent Mental Health (2015), p. 3, https://tinyurl.com/ynn37um4; William Ll. Parry-Jones, “The History of Child and Adolescent Psychiatry: Its Present Day Relevance,” Journal of Child Psychology and Psychiatry, January 1989, p. 4, https://tinyurl.com/2p9yftyh.

[39] Rey et al., ibid., p. 2.

[40] Michael Schuman, “History of child labor in the United States — part 2: the reform movement,” Monthly Labor Review, Bureau of Labor Statistics, January 2017, https://tinyurl.com/2p8wmvcf; Barbara Mantel, “Education Funding,” CQ Researcher, Aug. 31, 2018, p. 714.

[41] Parry-Jones, op. cit., p. 4.

[42] Rey et al., op. cit., pgs. 3, 5.

[43] Gerald N. Grob, Mental Illness and American Society: 1875–1940 (1983), pp. 30–31; Parry-Jones, op. cit., p. 5.

[44] Parry-Jones, ibid., pp. 5–6.

[45] Rey et al., op. cit., pgs. 5, 7.

[46] Ronald E. Dahl and Ahmad R. Hariri, “Lessons from G. Stanley Hall: Connecting New Research in Biological Sciences to the Study of Adolescent Development,” Journal of Research on Adolescence, November 2005, p. 368, https://tinyurl.com/46tchsph.

[47] “Reducing Disparities,” The Commonwealth Fund, https://tinyurl.com/4sru69vb.

[48] Ibid.

[49] Rey et al., op. cit., p. 16.

[50] Ibid., p. 17; “About,” Child Guidance Clinic for Central Connecticut, https://tinyurl.com/mhs5bzhf.

[51] “Dr. Aaron T. Beck,” The Beck Institute, https://tinyurl.com/2ptdpyns.

[52] Rey et al., op. cit., pp. 23–25; Thomas Insel, Healing: Our Path from Mental Illness to Mental Health (2022), p. 28.

[53] Allan V. Horwitz, DSM: A History of Psychiatry's Bible (2021), pgs. 1–2, 64–65.

[54] Ibid., pp. 152–153.

[55] Ibid., p. 5.

[56] Ibid., p. 3.

[57] Ibid., p. 151.

[58] Barbara Mantel, “Teen Suicide,” CQ Researcher, Sept. 12, 2014, p. 760, https://tinyurl.com/2v762yvr; Glen I. Spielmans, Tess Spence-Sing and Peter Parry, “Duty to Warn: Antidepressant Black Box Suicidality Warning Is Empirically Justified,” “Abstract,” Frontiers in Psychiatry, Feb. 13, 2020, https://tinyurl.com/2p85rnr3.

[59] Rey et al., op. cit., pp. 66; “Important Events in NIMH History,” National Institutes of Health, https://tinyurl.com/bddtkkks.

[60] Ibid., pgs. 434, 436; Alexander R. Thomas, “Ronald Reagan and the Commitment of the Mentally Ill: Capital, Interest Groups, and the Eclipse of Social Policy,” Electronic Journal of Sociology, 1998, https://tinyurl.com/bdekrbn3.

[61] Lois T. Flaherty and David Osher, “History of School-Based Mental Health Services in the United States,” Handbook of School Mental Health: Advancing Practice and Research (2002), p. 17, https://tinyurl.com/4ne6cukn.

[62] Barbara Mantel, “Mental Health Policy,” CQ Researcher, May 10, 2013, p. 438, https://tinyurl.com/53wj5t38.

[63] “Important Events in NIMH History,” op. cit.

[64] Mantel, “Teen Suicide,” op. cit., p. 758; National Suicide Prevention Lifeline, https://tinyurl.com/2p8mzn6e.

[65] Mantel, “Mental Health Policy,” op. cit., p. 439.

[66] Ibid., pp. 439–440.

[67] “How Have School Districts Spent ESSER Funds So Far?” Association of School Business Officials International, May 2022, https://tinyurl.com/42ec2dj6; “FACT SHEET,” op. cit.

[68] “President Biden's State of the Union Address,” The White House, March 1, 2022, https://tinyurl.com/4a8xmb9b.

[69] “FACT SHEET,” op. cit.

[70] “APA Statement on President Biden's National Strategy to Address Our Mental Health Crisis,” American Psychiatric Association, March 1, 2022, https://tinyurl.com/2p8sx587.

[71] “Strengthen Kids' Mental Health Now Bill Would Invest in Mental Health,” Children's Hospital Association, https://tinyurl.com/ystbaskr; “H.R.7236 — Strengthen Kids' Mental Health Now Act of 2022,” Congress.gov, https://tinyurl.com/bder4tpp.

[72] Emily Cochrane and Zolan Kanno-Youngs, “Biden Signs Gun Bill Into Law, Ending Years of Stalemate,” The New York Times, June 25, 2022, https://tinyurl.com/2t5bwmfa.

[73] Mike DeBonis, “Senate passes bipartisan gun violence bill, marking breakthrough,” The Washington Post, June 23, 2022, https://tinyurl.com/tw6nsybc; ibid.

[74] “NAMI Statement on Mental Health Investments in Bipartisan Senate Legislation,” National Alliance on Mental Illness, June 22, 2022, https://tinyurl.com/32jcffpt.

[75] “988 Key Messages,” Substance Abuse and Mental Health Services Administration, undated, https://tinyurl.com/2fs85dy6.

[76] Steve Eder, “As a Crisis Hotline Grows, So Do Fears It Won't Be Ready,” The New York Times, March 17, 2022, https://tinyurl.com/yyvuaj3f.

[77] Ibid.

[78] “Crisis Response,” National Alliance on Mental Illness, https://tinyurl.com/nhcxzete.

[79] “Preparedness Appears Low for Roll-Out of National 988 Mental Health Hotline,” press release, RAND Corporation, June 2, 2022, https://tinyurl.com/bdhdsuym.

[80] Eder, op. cit.; “FACT SHEET: President Biden to Announce Strategy to Address Our National Mental Health Crisis,” op. cit.

[81] Ibid.

[82] “988 Crisis Response State Legislation Map,” National Alliance on Mental Illness, https://tinyurl.com/mr3zzwt6.

[83] Eder, op. cit.

[84] “Maternal And Child Health Database,” National Conference of State Legislatures, May 2, 2022, https://tinyurl.com/muyfb93u.

[85] “NAMI Poll: Parents Want Mental Health Education in Schools, Mental Health Days Off for Students,” press release, National Alliance on Mental Illness, Dec. 15, 2021, https://tinyurl.com/uzmch9tj.

[86] “About Prescribing Psychologists,” American Psychological Association, https://tinyurl.com/yckhph2s.

[87] Ibid.

[88] “AACAP Releases Policy Statement on Psychologists Prescribing,” American Academy of Child & Adolescent Psychiatry, Sept. 12, 2017, https://tinyurl.com/y7j4ksvb.

[89] “Contract Supports Research into Personalized Treatments for Depression,” news release, Weill Cornell Medicine, Feb. 17, 2022, https://tinyurl.com/2d2ej75z.

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About the Author

Barbara Mantel is a freelance writer in New York City. She has been a Kiplinger Fellow and has won several journalism awards, including the National Press Club's Best Consumer Journalism Award and the Front Page Award. She holds a B.A. in history and economics from the University of Virginia and an M.A. in economics from Northwestern University. Her most recent CQ Researcher report was on wrongful convictions.

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