The kids are not okay: When back to school collides with a youth mental health crisis

Sixteen-year-old “Jeremy” is struggling. Prior to the pandemic he was an extroverted eighth grader with a friend group of 15 to 20 people and an almost perfect GPA. Then school shut down and he spent all of ninth grade at home. Jeremy is a hands-on learner and he found paying attention to a screen difficult. Gradually, he lost touch with most of his friends. Then his family was evicted and he spent a few weeks living in a hotel.

When Jeremy came back for tenth grade, his friend group was whittled down to two people and his GPA was a 2.8. His mental health tanked. This fall, Jeremy will be entering junior year and he’s dreading it. “It’s difficult to get up, get dressed, or go to work,” he says. “School starting up is going to add to the pressure.”

He’s worried about getting COVID and giving it to his sisters, and keeping his grades up so he can get into college. He has older friends whose grades dropped so much during the pandemic that they weren’t able to go. He’s also a teenager and worried about the eternal teenaged dilemma: trying to appear normal despite living in the most abnormal of times. “It’s stressful being around so many people, interacting with people you haven’t interacted with, but you try to act like you’re not affected because that’s what everyone else is doing,” Jeremy says.

Last December, U.S. Surgeon General Vivek Murthy announced that we are in the midst of a youth mental health crisis. According to the Centers for Disease Control and Prevention (CDC), approximately 44% of high school students feel persistently sad and hopeless, and emergency room visits for suicide attempts increased 31% in 2020 compared to 2019.

As a society, we’re doing a terrible job of helping. Part of the reason is stigma. Courtney Saunders, a therapist in Massachusetts, says she sees a lot of kids come in whose parents don’t understand the importance of mental health. “A lot of kids feel unheard and unseen, their experiences don’t seem as important as what the adults are dealing with,” she says. Part of the reason is structural—and it is to our detriment because, after all, the kids are our future.

“Missing a year of adaptive social experiences in the context of stress and disrupted routines can have dramatic effects later,” says Mitch Prinstein, chief science officer at the American Psychological Association.

Each crisis affects the whole

The population of youth needing mental care can be divided up into two categories. First, there’s youth who have a mental disorder—for example, bipolar disorder or schizophrenia—that needs to be treated. About 1 in 5 children ages 9 to 17 have a diagnosable mental disorder, and 1 in 10 have a disorder that causes significant impairment. Second, there’s the state of mental health in general, which is how well we’re doing as individuals emotionally and psychologically.

Untreated mental disorders and poor mental health can impact overall well-being and productivity. According to a 2018 survey from the Substance Abuse and Mental Health Services Administration, adolescents with a mental health issue were more likely to smoke, binge drink, and use illicit drugs. Poor mental health is also associated with lower school attendance, as well as dropping out of school, which can impact career outcomes.

“Even a small distortion in a kid’s trajectory can lead to a big path change—a different outcome than you would have [seen] otherwise,” says Prinstein.

Scaled up, untreated mental health problems can take a toll on the economy as a whole. In 2020, 30% of Social Security recipients had mental health disorders. Furthermore, within the insured population, only 10% of people account for 70% of healthcare costs. Yet almost half of this 10% have a mental health diagnosis. Their average healthcare cost per year is $12,221 compared to the average person’s $1,965, according to a study commissioned by the nonprofit Path Forward. In addition, untreated mental health problems often impact parent productivity. Multiply this by the scale of the current youth mental health crisis, and you have a parent productivity crisis too, Prinstein points out.

The youth mental health crisis didn’t come from nowhere—it was already simmering in the background prior to the pandemic, Vivek Murthy pointed out during the American Psychological Association’s annual conference this year. Between 2009 and 2019, according to the CDC, symptoms of depression increased 40% and suicidal behavior increased by 36%. The pandemic simply exacerbated the existing cracks in our infrastructure, and the cracks are many.

To begin with, about half of mental disorders in America go untreated, according to the National Alliance on Mental Health. On average, if a child is diagnosed with a mental disorder, it can take up to 11 years before they receive treatment—if they receive treatment at all. In 2018, 2 in 5 young adults with a mental disorder went untreated.

Part of this is due to a shortage of care providers: 77% of counties in the United States have a shortage of mental healthcare providers, and 55% of U.S. states have a shortage of child and adolescent psychiatrists. COVID exacerbated this: 62% of behavioral health clinics reported seeing their waitlists grow. Meanwhile, it’s unlikely this pipeline will be fixed any time soon: 82% of behavioral health clinics had trouble retaining employees, and 97% had trouble recruiting new employees to fill the gaps according to a 2021 study by the National Council for Mental Wellbeing.

Even if someone is able to see a mental healthcare provider, care is expensive. According to a 2019 study, a psychiatrist or therapist visit for a child is 10 times more likely to be out of network than a primary care office visit. Meanwhile, according to the same study, behavioral health providers receive 24% less in reimbursements than primary care providers.

“There are systemic differences in how we treat mental illness versus physical illness. The healthcare system has made incredible gains in many spaces such as cardiac disease, but we haven’t made gains in mental illness,” says Anna Bobb, an advisor at the Path Forward, which is aimed at reducing systemic inequalities in mental healthcare. “The healthcare system is an important tool for reversing that trend.”

Early screenings, collaborative care are key

In the long term, given how quickly the mental health crisis is escalating, it’s unsustainable to rely on a model where patients are constantly referred out for mental healthcare. Prinstein noted the importance of early screenings and collaborative care models where mental healthcare providers work in conjunction with primary care providers, so mental health can be regularly treated.

Care can also come from peers and communities. Tom Insel, the former director of the National Institute of Mental Health, noted that teens are doing well in group chat settings where they can bond with other people.

“Younger people want a tribe, people they can be vulnerable with, people they can give to and get help from,” he says. “People love that they’re able to help someone.”

Meanwhile, initiatives such as the Future Proofing Project in New South Wales have a multipronged strategy that includes long-term care, treatment, early intervention, and prevention in the form of teaching middle-school students social and emotional skills. However, critics point out that these skills implemented without an anti-racist lens, can lead to “white supremacy with a hug,” if justifiable outrage over social inequities is coded as a negative emotion that needs to be suppressed.

In the meantime, nonprofits and corporations are stepping in to fill in the gaps and push the levers and gears that make up the system. For example, LifeStance, a mental healthcare provider that employs clinicians and provides telehealth and in-person appointments, was started with the hope of improving accessibility to mental healthcare. “We go through what can be a daunting process for clinicians of enrolling them in insurance and making them in network,” says Danish Qureshi, the company’s chief operating officer.

On the philanthropy side, the Goodness Web, a foundation aimed at creating a network of mental healthcare solutions, handed out $5.3 million in grant money this year to mental health nonprofits, with the eventual goal of donating $100 million.

“We’re trying to look for the places where we can make the biggest impact,” says Mark Verdi, one of its founders. This year, one of its grants went to Path Forward, which pushed legislation to improve access to collaborative care through the House of Representatives. Path Forward works with coalitions of clinicians and healthcare purchasers, such as employers and unions, to include more mental healthcare providers in-network and increase their reimbursements.

All of these changes are in the works, but they will still take time to implement, and in the meantime, the slow days of summer are ticking away. Soon, Jeremy will need to return to school. He has a year to get his grades back up for college—his tenth grade English teacher, Lise Brody, is fervently rooting for him. “He’s a brilliant student and hungry to learn,” she says. “He’s done a lot of reading and self-education on his own, and I dearly hope he has access to the higher education opportunities he deserves.”

Jeremy would love to see a therapist, but that’s out of reach. Instead, he and his friends look up mental health tips online. He does is best to cope—by staying off Twitter, for instance, which he says he finds toxic as a Black male. He wishes his mom would give him a break, because she’s on his case to clean, but he also understands that she grew up in Dominican Republic and is from a different generation. Mostly, he wants to know he’s not alone. His tip for anyone who wants to help a teen out?  “Just check in,” he says. “It helps just knowing that someone cares.”