Supporting Youth Mental Health and the Critical Role of an Upstream Approach

By providing scaffolding to help build psychological flexibility among young people, we can not only support good mental health for life but reduce the mounting cost of mental healthcare.  

Mental health is the defining public health crisis of our time. According to the CDC, 42% of high school students felt so sad or hopeless that they could not engage in their regular activities for at least two weeks in 2021, an increase of 50% from 2011. The amount who seriously considered suicide soared to more than one in five, a 38% increase from 2011, and one-in-10 attempted suicide, a 25% increase from 2011. That means an average classroom of 30 has three students attempting to end their lives each year.  According to Pew Research, mental health is parents’ largest concern for their children, with 40% of parents being extremely or very worried about it.

To help reverse this devastating trend, healthcare systems need to shift “upstream” and focus on preclinical early intervention and prevention, as opposed to the current “downstream” reactive approach which only addresses issues after they’ve evolved into major disorders requiring acute treatment. On average, approximately 50% of lifetime mental health problems are established by age 14 and 75% are established by age 24. Unfortunately, healthcare systems globally are ignoring this reality and spending 90% of mental healthcare investments on acute mental healthcare treatment for adults, such as inpatient psychiatric care as well as hospital and emergency services.

This “downstream” approach is detrimental, inefficient, and exorbitantly expensive. It causes demand for treatment to outstrip supply and results in reactive treatment options that are condition-centric, episodic, and place-based. Healthcare systems are so heavily focused on (and overwhelmed by) the extreme instances requiring acute care that they are failing to find broader solutions to tackle the root of the problem.

We need to be proactive, shift upstream, and provide mental health support before people reach a critical breaking point. We need to support people during, not after, the 11 years it takes, on average, for initial mental illness symptoms to develop to the point of receiving traditional treatment.

Pre-clinical interventions are being vastly overlooked as the market struggles to address critically ill people. The lack of support for mental health issues until they become severe and urgent has created an enormous overlooked segment of the youth population that isn’t receiving help, but should be: the “missing middle.” This is the majority, roughly 60%-80%, of youth who are experiencing an emotional challenge, but they don’t have a mental health diagnosis, don’t think their issues are serious or ongoing enough to warrant a diagnosis and therapy, and aren’t facing an urgent crisis.

These are the young people who mask their problems, keep their heads down and just keep going. Often, they don’t recognize the severity of their struggles or don’t think medication or therapy would help, or don’t feel comfortable discussing the issue with parents or school counselors. Regardless, the “missing middle” needs far more support than they are currently getting. When left unchecked, mental health challenges often escalate and culminate into more serious problems. Prolonged exposure to stress, anxiety, and depression exacerbates each issue and increases the risk of people developing high acuity problems or having a crisis. Preventative upstream support not only builds healthier and more resilient young people, it also reduces healthcare costs by saving money on acute and chronic treatment down the line. Every $1 investment in prevention and early intervention for mental illness yields $2 to $10 in savings in healthcare costs, criminal and juvenile justice costs, and low productivity, according to a joint analysis by the National Academies of Sciences, Engineering, and Medicine.

Early intervention is particularly important because youth is the golden window of time during which environmental exposures have a pronounced impact on brain development, including the regulation of fear, stress, emotions, thoughts, and actions. We need to give young people the resources they need to build mental resilience and emotional coping skills during their early years to become healthier and higher-functioning adults.

Meeting young people where they are and where they feel comfortable

Successful upstream intervention with this generation of youth will require providing equitable access to behavioral health resources where they feel safe and comfortable. 

This means minimizing exposure to stigma by providing an anonymous digital platform where young people can privately and independently seek mental health support, which is not commonly available. In 2022, Pennsylvania began providing 150,000 students with access to Kooth’s anonymous digital mental health platform, and the user feedback demonstrated the importance of this anonymity; despite 65% of students feeling like they needed professional support, 63% did not feel comfortable speaking to friends or family about their mental wellbeing. If we want to help as many young people as possible, it’s imperative to give them equitable access to emotional health long before a diagnosis, which is generally not the case today.

It’s also imperative to make free, universally-accessible, and immediate support available 24/7. We heard time and time again from the Pennsylvania students that when they need help, they need it now – not in several weeks after they’ve obtained a diagnosis and scheduled a therapy appointment. 

The three primary reasons that Pennsylvania students are using Kooth are:

• 45% – To get mental wellbeing help that doesn’t require going to a counselor
• 59% – To get mental wellbeing help anytime/anywhere needed
• 62% – To connect with other people experiencing something similar

Finally, young people thrive when they have a sense of autonomy. We should give them the ability to address their mental health alongside their peers at their own pace – dipping into and out of a wide range of resources at their own leisure, with low commitment, minimal requirements, and no restrictions or funnels, except when people need to be referred to licensed therapy or other formal treatment. Young people need the chance to be themselves and don’t want to be commanded or controlled. We should encourage and facilitate them  to browse through and explore useful resources like therapeutic content, articles, stories from their peers, synchronous messaging and drop-in chats with mental health professionals, and forums moderated by licensed clinicians. 

Healthcare systems are very capable of providing this relevant, preventative support upstream, rather than only prioritizing acute mental healthcare treatment for adults. Society desperately needs it. 

According to the National Institute of Mental Health (NIMH,) mental health issues are costing the U.S. $467 billion per year, and they predominantly start with the youth, even though the nation’s spending on mental health does not remotely reflect that. Despite 70% of public schools reporting an increase of students who are seeking mental health services since before the COVID-19 pandemic and 76% reporting an increase in staff concerns about their students exhibiting symptoms such as depression, anxiety, and trauma, only half of school districts said they were equipped to provide needed care. As a result, the entry point for young people into the mental healthcare system is tragically often the emergency department. 

The majority of young people cannot be neglected just because their mental health challenges haven’t escalated or appeared. Instead, we must focus on enabling the youth to build psychological strength during their early years to create a more sustainable healthcare system and more importantly, a resilient, healthier, and higher-functioning population.

About Bob McCullough

Bob McCullough, PhD, is the vice president of Clinical Strategy for Kooth Digital Health. An associate professor of psychology at Missouri Baptist University and a licensed clinical social worker, Bob has extensive leadership experience in healthcare organizations including Cigna and Magellan Health, and behavioral health strategy experience at SilverCloud and ComPsych. He holds a master’s degree in social work from Washington University in St. Louis and a doctorate of philosophy from Newburgh Theological Seminary.

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