Adolescent Mental Health

Issues, Challenges, and Solutions

Adolescence is a transition phase from childhood to adulthood, which is marked by several biological, cognitive, and psychosocial changes. The characteristics which emerge during adolescence involve: a tendency to experiment and seek novel experiences, a heightened sense of vulnerability, a low risk perception, an intense desire for independence, and an inner search for self-identity which gradually shape up their personality throughout the developing years. It is a critical period characterized by neurobiological and physical maturation leading to enhanced psychological awareness and higher level of social and emotional interactions with peers and adults. From neurobiological perspective also adolescents can be viewed as “works in progress,” with academic, interpersonal, and emotional challenges, and exploring new territories using their talents, and experimenting with social identities.[¹] On one hand, it is a phase of tremendous growth in preparation of adults' roles and skills to sustain pressures and challenges, whereas on the other, it is transition phase that can increase risk of various psychological disorders, adjustment problems, and suicide.[²] Positive and promotive mental health in this period ensures a smooth progress to later adult life.[³]

ADOLESCENT PSYCHIATRIC BURDEN

Worldwide, it is estimated that 10%–20% of adolescents' experience mental health conditions, yet the majority of times, it remains underdiagnosed and undertreated. Signs of poor mental health are overlooked for several reasons, such as a lack of knowledge or awareness of mental health among health workers and also the stigma that prevent from seeking help.[⁴] According to the 2011 census, around one-fourth of the Indian population is adolescent (253 million).[⁵⁶] As per the National Mental Health Survey of India (2015–2016), the prevalence of psychiatric disorders among adolescents (13–17 years) is reported around 7.3%.[⁷] Yet, very little attention has been paid to the mental health issues of this age group.

DIMENSIONS OF MENTAL HEALTH PROBLEMS

The prevalence and pattern of mental and behavioral disorders show a change during adolescence. The mental health need of this population group is distinct from both children and adults. Nearly 50% of adult psychiatric disorders begin before the age of 14 years.[³] Preexisting psychiatric disorders during childhood may act as predisposing or precipitating factor for mental illness during the adolescent period. These impairing psychiatric disorders emerge in approximately 20% of the adolescent population.[¹]

MAJOR PSYCHIATRIC DISORDERS IN ADOLESCENCE

Depressive disorders become more prevalent, behavioral disturbances, such as suicidality, eating disorders, and substance abuse, begin to emerge in these years. The prevalence rates increase from 1% to 2% in childhood to around 10%–20% by late adolescence, similar to adults.[⁸] Depression and stress are more prevalent among school-going adolescent girls. Approximately 40%–90% of adolescents with depression have a comorbid psychiatric disorder such as anxiety disorders, conduct disorders, substance abuse, and personality disorders in the case of adolescents.[⁸⁹] Anxiety disorders are also commonly encountered among the adolescent population.[¹⁰] In India, suicide is a leading cause of death among young people as 25% of deaths in adolescent boys and 50%–75% of deaths in adolescent girls is due to suicide. Every hour, one student commits suicide in India, according to the National Crime Records Bureau report in 2015.[²] Community surveys suggest that tobacco and alcohol are prevalent substances of abuse among Indian adolescents. The experimentation with “gateway” drugs such as tobacco, alcohol, and inhalants may lead to indulgence in high-risk behaviors. The substance use has spread to different areas of the world, including India and increasing in adolescents' age groups even in the distant regions. In this issue, Majumder et al.[⁵] and Keyho et al.[⁶] have assessed psychiatric morbidity in adolescent patients and school-going adolescents in North-Eastern India. Majumder et al. have assessed psychiatric morbidity in 474 consecutive adolescent patients (10–19 years) attending to psychiatric services at tertiary care center in Manipur and reported the most common disorder as neurotic, stress-related, and somatoform disorders (41%), followed by psychotropic substance use disorders (21%) (including opioid dependence in 14% and cannabis dependence in 3% of adolescent).[⁵] While the most common disorder was substance use disorders (37%) in adolescent boys, and neurotic, stress-related, and somatoform disorders (61%) in adolescent girls.[⁵] Keyho et al. have assessed the mental health status of 702 school-going adolescents (13–19 years) in Kohima and reported emotional problems in 17%, hyperactivity in 16%, and conduct problem in 15%.[⁶]

Another issue which needs focus and active intervention is sexual abuse which has long been the subject of the study in the field of mental and social health. Nearly one-third of higher secondary school-going adolescents reported experiencing some form of sexual abuse over the past 12 months and 6% reported experiencing forced sex.[⁸] The Internet and social media are ubiquitous among adolescents and serve as platforms to socialize and to communicate. The “digital revolution” has highlighted the adaptive nature of the adolescent brain in its ability to incorporate these technologies. Reports had also indicated that about 90% of adolescents use the Internet in many ways, including messaging, blogging, posting photos, videos, and stories.[¹] Positive effects of the Internet identified for adolescents include increased communication, increased access to academic information, and familiarity with social and cultural habits of people worldwide. On the other side, pathological Internet use/Internet addiction is reported high in Indian schools (prevalence of 11.8%) and college settings (prevalence of 42.9%). The consequences of these are manifold ranging from alteration of biological functions, substance use to self-harm, and even death.[¹¹]

FACTORS AFFECTING THE PSYCHOLOGICAL HEALTH OF INDIAN ADOLESCENTS

There is a complex biopsychosocial framework of risk factors operating in the lives of adolescents which include self, home, school, peer group, and neighborhood which may be associated with the mental health disorder.[¹⁸] Risk factors include all variables that increase the probability that a given child or adolescent will develop psychopathology while protective factors decrease the risk of developing psychopathology. Rarely, a single-risk-factor accounts for the emergence and inhibition of a psychiatric disorder.[¹¹²] There is a significant effect of the following factors on the mental health of adolescents: recent sociocultural changes, poor social support, the breakdown of extended and joint families, the ambiguity of societal values, and increasing gap between aspirations and possible achievements, substance abuse, etc.[⁵¹²¹³]

BARRIERS IN THE SERVICE DELIVERY

Stigma about mental health and lack of education and awareness forms one of the factors for seeking psychiatric consultation. Above that beliefs about mental illnesses influence help-seeking attitudes and patterns in people. In India, only one-third of the families (37.5%) of children and adolescents with mental disorders perceived that their children had any psychiatric problem.[¹⁴] At the stakeholder levels limitations of the existing policies and programs, the lack of alignment across them and the fragmentation of governance of adolescent mental health between ministries and departments, are likely to pose major barriers to their effective and efficient implementation.[¹⁵]

INTERVENTIONS FOR PSYCHIATRIC DISORDERS IN YOUTH: PROPOSED SOLUTIONS

There is a need for a special emphasis on adolescent mental health at different levels with coordinated efforts. To strengthen child and adolescent mental health care in a country, it should be supported by the necessary policies, programs, legislation, policy, budget, primary-care system, training programs, and service delivery system.[¹⁶] Interventions to address psychiatric disorders in youth are universal, targeted, and clinical. Universal interventions also termed primary prevention, are received by all children and families within a specific geographical distribution. There is potential scope for primary or preventive interventions at this age. Targeted interventions are designed for children at increased risk for psychiatric disorders and Clinical interventions provide treatment to adolescent with psychiatric disorder which includes psychosocial, psychopharmacological, and other environmental interventions.[¹⁷¹⁸] Preventive efforts not only improve the mental health of young but also may have far-reaching consequences in reducing adult psychiatric morbidity.[¹²]

ROLE OF PARENTS AND TEACHERS

Schools and colleges may play a vital role in the development of adolescents and provide a room and scope for intervention. Family as an institution continues to play a large role in influencing adolescents across all sections of the society in India. Parental support and healthy parenting have been identified as contributors to better mental health outcomes and reduction in help-seeking barriers in their children.[¹⁹] Sensitization and training of teachers and counselors to handle adolescent mental health issues can further help in early identification of mental health problems. Drug awareness campaigns should be regularly conducted in schools and colleges with the facility of screening in the high-risk population.[³] There should be a focus on enhancing social skills to resist peer pressure and the ability to say “no” to drugs. Special attention should be devoted to children with scholastic difficulties or poor academic achievements with an encouraging and supportive approach. Resilience-focused interventions such as capacity building strategies, and coping skills may be designed to enhance resilience thereby positively influencing mental health.[²⁰] Interventions such as “health education” pertaining to adolescent health, sex education, and pubertal changes have shown improvement in knowledge among adolescent girls.[²¹] Model-based health delivery approaches such as mental health promotion such as yoga, life skills approach in secondary schools has shown significant results and can be further strengthened.[²²²³²⁴]

COLLABORATIVE ROLE OF HEALTH PROFESSIONALS

Skilled and competent workforce is need of the hour, especially in dealing with adolescent mental health at various levels. Professionals such as physicians, pediatricians, and nurses can be trained in relevant aspects of adolescent mental health promotion and preventive activities. The key to good liaison is the better understanding of respective roles and responsibilities by each professional of the multidisciplinary team.[⁸] With development of effective linkages along with adequate referral system may further help in management of priority mental health disorders in children and adolescents and dealing with emergency conditions like suicide. There is also a need to build on indigenous ways of child and adolescent health promotion. Computer-assisted interventions may be employed, especially for urban adolescents.[¹⁵] Policies and programs need to be better aligned with evidence-based practices emerging from both scientific studies and experience with the regular update of practice guidelines will further help in increasing the competence in this direction.[²⁵]

NEED FOR EFFECTIVE INTER-SECTORAL LINKAGES AND PUBLIC HEALTH APPROACH

There is a need to develop effective inter-sectoral linkages comprising the educational, legal and juvenile justice system, social welfare, and voluntary organizations and nongovernmental organizations with more effective linkage of adolescent mental health with the national programs such as National Rural Health Mission and the Reproductive and Child Health Programme.[⁸]

Seeing the huge-dimensional problem development of community and primary health can be a feasible, acceptable, and affordable approach for catering to the mental health needs of Indian children.[²⁶²⁷] This may be achieved through mobile health camps, regular screening and health check-ups like other medical morbidities at primary levels with the involvement of Anganwadi workers or primary care clinics under district mental health program.[³] It is important to establish a body at center and state levels to have an effective mechanism for coordination and monitoring of services to facilitate an effective liaison with different organizations on adolescent mental health issues.[³⁸]

To conclude, child and adolescent mental health is a shared responsibility. For any interventions to be effective, there is a need for synergy between different stakeholders. Adolescents having mental health problems and disorders, need to have access to timely, integrated, high-quality, multi-disciplinary mental health services to ensure effective assessment, treatment, and support. The preservation and promotion of mental health in the young population have conventionally been viewed as an individual or family responsibility; however, it is important to emphasize it at a much broader level. There is a need to promote the concept of positive health with public health approaches including expansion of the community services for mental disorders.[³¹²] There is an urgent need to explore newer models of service delivery apart from standard models of hospital-based care. The newer service delivery models should incorporate cross-cultural, multilingual, and multiregional requirements. A positive step in this direction could be the formulation of mental health policy specifically for the younger population to provide a developmental framework to enhance adolescent mental health.