AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.
In today’s episode of Moving Medicine, Sandra DeJong, MD, a child and adolescent psychiatrist and secretary of the American Psychiatric Association Board of Trustees, discusses teen mental health issues and how they’ve been exacerbated by the COVID-19 pandemic. AMA Chief Experience Officer Todd Unger hosts.
If you or someone you know is struggling with mental health, dial 988 for the 988 Suicide & Crisis Lifeline. For more information visit: 988lifeline.org.
- Sandra DeJong, MD, child and adolescent psychiatrist; secretary, American Psychiatric Association Board of Trustees
Unger: Hello. This is the American Medical Association's Moving Medicine video and podcast. Today we're talking about teen mental health issues and how they've been exacerbated by the COVID-19 pandemic. I'm joined today by Dr. Sandra DeJong, a child and adolescent psychiatrist in Cambridge, Massachusetts, who is also secretary of the American Psychiatric Association Board of Trustees. I'm Todd Unger, AMA's chief experience officer in Chicago.
Dr. DeJong, thank you so much for being with us today. In the fall of 2021, several associations declared a national emergency in child and adolescent mental health. And, later, in December, the U.S. surgeon general, in a rare public advisory, warned of a, quote, "devastating mental health crisis among American teens."
Let's just start out today with a little context. Have you ever seen anything like this happen before? And what exactly does this mean? Are we still in this emergency situation right now with teens and mental health?
Dr. DeJong: Yeah, so it really is unprecedented in my experience to have both this emergency declaration and the surgeon general's advisory. And I think it really is because the situation itself is unprecedented. So what makes it an emergency? We have much higher rates of things like anxiety, depression, suicide.
But it's also, really, the impact of the psychosocial effects of COVID, so things like teenagers confronting illness and death, family stress due to unemployment and financial pressures, increased rates of domestic violence, increased use of parental substance abuse. At the same time, kids have been out of school, fewer adults monitoring them. Schools have been closed.
And we have to remember that lots of kids around this country get food from school, get mental health services from school. They've been cut off from their peers, which is critical for youth to develop that sense of identity, which this stage is really all about. Academic skill loss has been a factor, disengagement from school and, really, just lots of loss of structure and routine.
And we really don't know what the effect of this is going to be over time. We think that vulnerable youth are going to be more at risk, those who are already at risk. But, really, I think we have to think about this as a whole generation at potentially increased risk.
Unger: Wow, no shortage of drivers from that list you just gave. When you look at where we are right now, what you see as the biggest risks to adolescents today and has this shifted over time?
Dr. DeJong: Yeah, I think things are getting better. Schools are mostly back in person. But there's a lot of uncertainty as to what life will look like in terms of schools and health care and all of that. And we still have a really ... for example, in my clinic, my hospital clinic has the biggest waiting list we've ever had. So things still feel pretty tough in the mental health arena.
I think this persistent high stress and loss at this key stage of development is likely to have a long-term sequelae. It may even have epigenetic impacts on brain development. And we will have—and get passed over succeeding generations. So there's a lot going on with this.
And then it's been compounded by other kinds of psychosocial stressors, so, certainly, what's been going on with climate change and the impact of that on youth, the activity around systemic racism. So there's a sense of youth having been really burdened. And I think while they've realized that things like vaccinations and antiviral medications can help take care of the physical symptoms of COVID, the mental health and the social-emotional impacts have been much harder to break free from.
Unger: That is, I mean, a terrible amount of burden. And the generational impact that you talked about is something serious and, I guess, something we'll see play out. When we talk often about different topics related to the pandemic, there's kind of a common thing, which is there was something that was already not great beforehand that was exacerbated by the pandemic.
When you take yourself back pre-pandemic, were you already seeing signs in your practice that teen mental health was on a decline? Or were you seeing trouble spots before COVID hit?
Dr. DeJong: Yeah, so it's absolutely true, I think, that things were already in decline, and that COVID seems to have accelerated and exacerbated that decline. So I started outpatient practice in 2001. And at that time, we were already seeing the rates of anxiety, depression, suicide, substance use going up in this country. And there's been a lot of speculation about the cause of that, what role social media had and so forth. But things were already getting worse.
And I would also say that there was already back then, the system for youth mental health care was already struggling. And I remember very vividly starting my practice. And within a very short period of time, I had a six-month wait list. So this has been going on for some time, yeah.
Unger: So a real shortage on the physician end in this space?
Dr. DeJong: Absolutely. So we know, unfortunately, that we have a national crisis in terms of the shortage of child psychiatrists. We have only 14 child psychiatrists per 100,000 youth in this country. And about half of youth aren't getting care for their mental health problem for those who need it, so big, big access problem, yep.
Unger: Dr. DeJong, with more teens struggling with mental issues, like you've outlined, and not offset whatsoever by the supply of actual folks that can help them, is stigma still an issue in this population or a barrier to getting teens asking for help or getting help?
Dr. DeJong: It's interesting, in my experience, teens have, in general, been much more open to talking about mental health concerns than have the parental generation. And I actually think what's shifted is that adults are now more open to thinking about it. Everybody from Michelle Obama reporting that she was depressed to physicians themselves have been claiming their own mental health concerns in public. And I think they are now more open to listening to what youth have been talking about for some time.
I would just add to that, though, I think it's important to recognize that there are certain groups for whom mental health issues still are highly stigmatized. And we really have to be particularly vigilant about those groups.
Unger: Do you want to talk specifically more about that?
Dr. DeJong: Well, so, for example, we know that in Asian American communities, the idea of having a mental health problem and going and seeking mental health care is a huge source of shame, potentially, in their communities. We, in my clinic, work with a lot of Asian American youth and, again, it's really not part of their culture to get mental health care. So I think things are overall getting better. And I think as the overall stigma decreases, hopefully, it's likely to decrease for everybody. But we do need to be sensitive to that issue.
Unger: Like with, again, so many things during the pandemic data and having enough data to really guide decisions has been really important in kind of catching up. When you look at this crisis, do you feel like we have enough data for the profession as a whole to respond well? And if not what, questions still are yet to be answered?
Dr. DeJong: Yeah, I have to say when you look at youth mental health data, in my opinion, it's just not as good as one would wish. We have data that are based on surveys of self-report, for example, by parents and kids and a lot of synthesis of that data. But what we don't have is systemic data. Even when you compare systems of care across states, they use different terminology for the same kinds of services. And so trying to do comparisons is really quite tricky.
We also don't have enough longitudinal data. So we really need to know what's been the impact and what will be the impact of COVID on youth over time. So that's going to take years of study. And those kinds of large longitudinal studies are just difficult to do.
And I think we need to understand better where the holes in our system of care. And I would love to know where are the communities where things have gone better than we might have predicted and what were they doing right. What works? What fosters resilience in communities and populations? I think that—
Unger: Have you heard anything to that effect that's promising?
Dr. DeJong: Well, I think there are a lot of efforts underway. I think what I'm seeing, which does really give me hope, is an emphasis on community resilience and building up community systems of support, which I think is really going to be where the money is.
Unger: Well, some have said that the medical system hasn't been able to keep up with a lot of the changes. Certainly, they come on hard and fast over the past two years. That's put a lot of pressure on emergency department physicians and pediatricians, kind of put them on the front lines of this particular crisis. What challenges does this pose? And what do we do about that?
Dr. DeJong: Yeah, so they are in an incredibly difficult situation and need our support. And really, what we need, I think, is a system of care based on collaboration and consultation. So ideally, emergency physicians would have at least one child psychiatrist they could call for a remote consultation. And we need to be thinking much more about early intervention and prevention in these large communities because for sure, these folks aren't prepared to do it on their own.
Having said that, I will say that sometimes catching a teen in a moment of crisis, like an emergency room physician does, for example, can be an incredibly important point of intervention. And picking up on depressive symptoms or a lack of engagement in school or a dysfunctional family at that point can really, and in a supportive empathic way, I think, can really facilitate an entrée into the mental health system and help.
Unger: When you think about the reality that we're in right now in this particular situation, what do pediatricians and emergency medicine physicians need to know about treating teens with mental health issues? And are any red flags they may not be aware of?
Dr. DeJong: Yeah, I think one of the tricky things is that adolescent depression can present quite differently from adult depression. So we know youth can be eating more, sleeping more. And, socially, they can actually look quite OK. Parents often say they seem fine with their friends.
But inside, they're quite withdrawn and they're really not feeling plugged in. And they may be feeling very stuck. And those are all red flags. They can be quite irritable as well.
So asking about all of those things, you really want to know who does this teenager field connected to? Is there one adult in their life they feel connected to? Because that person can often really change the course.
Unger: And sometimes that's their pediatrician.
Dr. DeJong: Absolutely.
Unger: Pediatricians may have a direct line to parents. How should they be communicating to parents about issues like this? And can and should parents be playing a larger role?
Dr. DeJong: It's critical. We talk in child psychiatry about family-centered care. And that's really the approach we want. No one individual can do this alone. It really needs to be a family system centered approach.
And the caveat though, of course, is that teenagers get very worried when doctors talk to their parents about their stuff. So we have to respect youth's autonomy and right to confidentiality. But we really want to push gently towards open communication and mutual support, I think owning this as a family rather than pointing fingers to any single individual struggling and just saying, this has been a really tough time.
And I think pediatricians can help parents get the support they need and can also help them own their own areas of strength and resilience and help identify that in their kids. And then the whole family can feel stronger together. So I think it's an important approach.
Unger: Well, it's a pretty distressing situation and one with long-term implications. When you think about where we are right now, what are the short-term solutions and maybe the longer-term ones that you think we need to prioritize to address this crisis in the months ahead?
Dr. DeJong: Well, I think in the short term, we need to try to pivot to a more positive, future-looking stance. We're not going to be in this forever. I mean, it's going to be part of a new normal. But things are getting much better.
I really encourage people to connect with others. That was missing so much during COVID. And I think it's such a huge part of our mental health to feel connected and part of a greater whole. So I often refer people to community efforts or encourage them to have family events or get together with their friends, those kinds of things as a way to sort of pull together after this really challenging time.
But, look, really, youth mental health, child mental health, our system is more like Swiss cheese than anything else. It's got a lot of holes in it. And I think we're going to need to really look at ensuring that we have a system of care that isn't just about beds.
I know we hear a lot about the boarding crisis and kids waiting for beds. But we really need to be looking at the community level, schools, law enforcement, community organizations up through primary care to urgent access to care. So, hopefully, this new 988 hotline will be helpful and then looking at the more acute services for care.
But if we can get in early to provide kids what they need, I don't think we're going to need as many hospital beds as we think. And that's really critical because we know there's no health without mental health, and our youth really truly are our future. And we really do think they're at risk in ways that we are only just beginning to understand. And so we really need to be close and watchful and be there for them.
Unger: Dr. DeJong, thank you so much for being here today. It's an incredible perspective and shed more light on a problem that is so incredibly serious. That wraps up today's episode.
We'll be back with another Moving Medicine segment shortly. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today and please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.