Clinical Context

The kids are not alright.

The Youth Behavior Risk Survey includes a broad assessment of mental health, substance use, and sexual health among US high school students, and in 2021 the survey was distributed for the first time during the COVID-19 pandemic. The results for mental health among adolescents were highly disturbing.

Forty-two percent of respondents reported persistent feelings of sadness or hopelessness. This figure was significantly worse than results from 2019 (37%) and 2011 (28%). The prevalence of sadness/hopelessness was 57% among girls and 29% among boys, and girls were more than twice as likely to consider suicide compared with boys. Overall, 22% of youth reported seriously considering suicide and 18% had made a plan for suicide. Ten percent reported a suicide attempt.

Evidence-based treatment (EBT), using guidance from manuals, has been associated with better outcomes for mental illness among young people when compared with usual care, but uptake of EBT has been highly variable. The current study assesses characteristics associated with provider use or nonuse of EBT in caring for children and adolescents with mental illness.

Study Synopsis and Perspective

Last month, the Centers for Disease Control and Prevention reported that teenagers are facing the highest levels of sadness and sexual violence in a decade. The agency also found that 1 in 5 high school students seriously considered attempting suicide in 2021.

The reaction to the new data is largely familiar: experts yet again are calling for multidisciplinary action.^[1] Increased support for teenage mental health may look like more frequent conversations about depression and suicide at home, mental health first aid in schools, and recruitment of trained youths to support their peers through crisis.^[2] However, obstacles to implementing such actions leave pediatricians wary that they will have to play an outsized role in managing the crisis in teenage mental health.

“This cannot be solely on the shoulders of pediatricians. It’s not fair nor appropriate in terms of comprehensive mental health treatment to these children,” said Christine Page-Lopez, DO, MPH, a pediatric mental health expert from the American Academy of Pediatrics (AAP). “We need mental health professionals, therapists, counselors, social workers, psychiatrists, and schools more involved.”

The pediatric mental health crisis now leads the annual top 10 list of concerns for ECRI, a nonprofit group focused on patient safety, ahead of physical and verbal abuse of healthcare workers and uncertainty in maternal-fetal medicine.

“Even before COVID-19, the impact of social media, gun violence, and other socioeconomic factors were causing elevated rates of depression and anxiety in children,” said Marcus Schabacker, MD, PhD, president and CEO of ECRI, in a statement. “The challenges caused by the pandemic turned a bad situation into a crisis. We’re approaching a national public health emergency.”

The number of medical training programs in adolescent medicine has crept up during the past decade, going from 23 in 2014 to 28 in 2022, according to the American Board of Pediatrics. But the number of trainees in that subspecialty remains small, at 28 in 2014 and 37 in 2022, board figures show.

Carol Vidal, MD, PhD, MPH, a child and adolescent psychiatrist at the Johns Hopkins Children’s Center in Baltimore, Maryland, said that community health workers, media professionals, and schools must be engaged to provide strong, evidence-based interventions, as well as more opportunities for children, regardless of income.^[3]

Pediatricians can refer teenagers to psychiatrists, psychologists, and social workers, but often doing so often means that patients experience delays in getting needed care. The United States has approximately 8300 practicing child and adolescent psychiatrists and more than 15 million youth in need of mental health support, according to the American Academy of Child & Adolescent Psychiatry. Even with approximately 13,500 therapists and 700,000 social workers in the United States, far more mental health experts are needed to address the teenage mental health crisis, according to Sue Poynter, MD, director of the pediatric residency training program at Cincinnati Children’s Hospital Medical Center in Ohio.

Many primary care clinicians do not feel comfortable diagnosing and treating mental health conditions, which have not been a required part of pediatric training, leaving a marked shortage, according to Dr Poynter.^[4]

“It takes time to train more providers, whether those are general pediatricians comfortable with mental health or more mental health providers, so demand will continue to outpace supply for some time,” Dr Poynter said.

Pediatricians may also need to start taking an even larger role in medical management of mood, said Margaret Thew, APNP, an urgent care and adolescent medicine family nurse practitioner at Children’s Wisconsin, in Milwaukee.

“Everyone needs to get a bit more comfortable in prescribing medications and managing mild to moderate mental health concerns,” Page-Lopez said. “There’s more continuing medical education conferences, seminars, and fellowships for healthcare providers in pediatric care to gain more experience, so it is absolutely within our scope of practice to be able to manage these children.”

Another resource available to prescribers are Board Certified Psychiatric Pharmacists, trained to care for patients with psychiatric illness including children and adolescents. Prescribers can utilize these members of the team for questions regarding dosing, interactions with other medications, and potential side effects of their proposed treatment plan.

The AAP recommends that pediatricians perform additional screenings at wellness visits, including assessments for maternal and childhood depression, autism, and suicide risk.^[5] However, increased screening recommendations from the AAP once again bring pressure on pediatricians to fit everything into a 20-minute visit.

Because of the brief nature of wellness visits, parents and school officials should also create spaces in which youths feel comfortable talking not only about their mental health but also about explicit feelings and thoughts of suicide, said Jessica Hamilton, PhD, an assistant professor of psychology at Rutgers University in New Brunswick, New Jersey.

Dr Hamilton acknowledges that talking about mental health and suicide is challenging. However, an open invitation to talk would give teenagers the opportunity to communicate their distress and get the help they need when ready.

“Asking about suicide does not put the thought in their head or make them more likely to act it” out, she said. “It simply gives teens the opportunity to communicate their distress and get help they need.”

The sources in this story have disclosed no relevant financial relationships.

Clinical Implications

• The 2021 US Youth Behavior Risk Survey found that 42% of respondents reported persistent feelings of sadness or hopelessness. This figure was significantly worse than results from 2019 (37%) and 2011 (28%). The prevalence of sadness/hopelessness was 57% among girls and 29% among boys, and girls were more than twice as likely to consider suicide compared with boys. Overall, 22% of youth reported seriously considering suicide and 18% had made a plan for suicide; 10% reported a suicide attempt.
• Variables associated with higher use of EBT in the current study of mental healthcare among children and adolescents included greater interest in learning theory, more positive attitudes toward innovation and evidence-based care, more recent training completion date, and fewer low-income patients. In contrast, the primary patient health issue, the percent of patients from minority racial/ethnic backgrounds, comorbid illness, patient age, and professional discipline were not significantly associated with the use of EBT.
• Implications for the Healthcare Team: To ensure children and adolescents receive adequate mental health support, open discussion about mental health and suicide should become the norm.

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