Meeting the challenge of adolescent mental health

Views on adolescence and adolescent mental health have recently shifted. Puberty undoubtedly brings adjustments to physical maturity, changing roles within families and with peers, and the emergence of a more independent lifestyle. Most young people negotiate these changes without upheaval. By and large, they also avoid extremes in early experimentation with alcohol and recreational drugs, dieting and sexual activity.² Given this more sanguine perspective on adolescent development, emerging concerns about adolescent mental health seem at first sight unwarranted. However, around one in five adolescents do pass through a more prolonged phase of emotional difficulties in which experiences of depression and anxiety are common.³ There is evidence that such difficulties have become commoner. Surveys of adults in several Western countries suggest that cohorts since World War II have higher rates of adolescent-onset psychiatric problems. North American studies, for example, have indicated up to a tenfold rise in rates of adolescent depression in more recently born groups.⁴ As a consequence, the late teens and early twenties appear to be the period of peak incidence for depression.⁵

Adolescent mental health has assumed importance for other reasons. One derives from the continuities between adolescent and adult psychopathology. Prospective studies indicate that adolescent depression, far from subsiding in early adulthood, substantially elevates the risk of a later disorder.⁶ A second reason lies in links between mental health and other indices of adolescent health status. Trends in health-damaging behaviour parallel those in adolescent mental health problems. The age of onset of alcohol and substance abuse and sexual risk behaviours has fallen, so that they have joined eating disorders and deliberate self-harm as adolescent health concerns.

These parallel trends have prompted questions about possible causal links between adolescent mental health and behavioural problems. Such a link is probably clearest for suicidal behaviour, in which depressive symptoms are the strongest risk factors for both fatal and non-fatal self-harm.^7,8 Risks for suicidal behaviour increase with the level of depressive symptoms. For the most part, adolescent suicidal behaviour does not result from a clear intent to kill oneself. Rather, it is best understood as a maladaptive reaction to the distress, negative self-evaluation and high levels of interpersonal conflict that commonly accompany depression.⁹

The implications for intervention are great. Self-harming adolescents commonly experience depressive symptoms but many will fall short of meeting criteria for depressive disorder. Preventive and clinical intervention efforts should therefore be broad-based and not restricted to those with a florid mental disorder. For this reason, "population-based" interventions aimed at promoting well-being and reducing depressive symptoms across a whole population, rather than focusing on those at highest risk, seem an attractive but neglected avenue for the prevention of suicidal behaviour.¹⁰

Adolescent psychopathology has been linked to other health-damaging behaviours.^11,12 Depressive and anxiety symptoms are associated with adolescent alcohol and substance abuse, and their presence predicts progression to dependent patterns of consumption.¹³ Extreme weight control behaviours,¹⁴ adolescent smoking¹⁵ and early teenage pregnancy¹⁶ are among other behaviours associated with psychological disorders.

Clarification of the underlying risk processes may offer strategies for intervention. Self-medication to relieve emotional distress may explain associations with smoking, alcohol and substance abuse, and points to a need to learn alternative means of dealing with emotional distress.¹⁵ Susceptibility to peer influences may be another explanation. Loss of self-confidence and social anxiety, which commonly accompany depression, may bring a greater readiness to adopt peer attitudes and behaviours as a means of engaging with a social group. In some instances, where psychopathology and health-damaging behaviour share a common origin, intervention may best focus on antecedent familial or social circumstances. Whatever the risk process, successful interventions for adolescent mental health problems are likely to bring other health benefits.

The emerging importance of adolescent mental health carries implications for adolescent health care and health promotion. Within psychiatry this has been recognised in calls for a greater emphasis on the management of adolescent onset disorders.¹⁷ However, psychiatric services can deal only with a minority of adolescents with common disorders such as depression and anxiety, so responsibility for early recognition and treatment rests more broadly. General practitioners are likely to play a major role. This has been recognised in the National Health and Medical Research Council guidelines for the treatment of adolescent depression, which are accompanied by guidelines for the general practitioner in the psychological and medical management of adolescent depression.¹⁸ These skills are likely to play a central role in dealing with adolescent behavioural problems such as substance abuse, and, when dealing with associated emotional problems, may do much to prevent progression to dependent patterns of use.

Meeting the challenge of adolescent mental health must ultimately extend to preventive action. Interventions to support families, schools, youth and community organisations in the creation of social environments which promote mental health and well-being should bring gains in adolescent mental health, which in turn are likely to bring diverse health benefits.

George C Patton
Associate Professor in Adolescent Psychiatry
Centre for Adolescent Health, Department of Paediatrics
University of Melbourne, VIC

1. Hall GS. Adolescence: Its psychology and its relations to physiology, anthropology, sociology, sex, crime, religion and education. London: Sidney Appleton, 1905.
2. Hibbert M, Caust J, Patton G, et al. The health of young people in Victoria. Melbourne: Centre for Adolescent Health, 1996.
3. Offer D, Schonert-Reichl KA. Debunking the myths of adolescence: findings from recent research. J Am Acad Child Adolesc Psychiatry 1992; 31: 1003-1014.
4. Burke KC, Burke JD Jr, Rae DS, Regier DA. Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five US community populations. Arch Gen Psychiatry 1991; 48: 789-795.
5. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8-19.
6. Harrington R. The natural history and treatment of child and adolescent affective /disorders. J Child Psychol Psychiat 1992; 33: 1287-1302.
7. Patton GC, Harris R, Carlin JB, et al. Adolescent suicidal behaviours: a population based study of risk. Psychol Med 1997; 27. In press.
8. Brent DA. Depression and suicide in children and adolescents. Pediatrics Rev 1993; 14: 380-388.
9. Kienhorst I, de Wilde EJ, Diekstra RFW, Wolters WHG. Adolescents' image of their suicide attempt. J Am Acad Child Adolesc Psychiatry 1995; 34: 623-628.
10. Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992.
11. Fergusson DM, Horwood LJ, Lynskey MT. The comorbidities of adolescent problem behaviours: A latent class model. J Abnormal Child Psychol 1994; 22: 339-353.
12. Feehan M, McGee R, Raja SN, Williams SM. DSM-III-R disorders in New Zealand 18-year-olds. Aust N Z J Psychiatry 1994; 28: 87-99.
13. Jones P, Rodgers B, Murray R, Marmot M. Child developmental risk factors for adult schizophrenia in the British 1946 birth cohort. Lancet 1994; 344: 1398-1402.
14. Patton GC, Carlin JB, Shao Q, et al. Adolescent dieting: health weight control or borderline eating disorder? J Child Psychol Psychiatry 1997; 38: 299-306.
15. Patton GC, Hibbert MH, Rosier MJ, et al. Is smoking associated with depression and anxiety in teenagers? Am J Pub Health 1996; 86: 225-300.
16. Kovacs M, Krol RS, Voti L. Early psychopathology and risk for teenage pregnancy among clinically referred girls. J Am Acad Child Adolesc Psychiatry 1994; 33: 106-114.
17. McGorry P. The Centre for Young People's Mental Health: blending epidemiology and developmental psychiatry. Australasian Psychiatry 1996; 4: 243-247.
18. Quality of Care and Health Outcomes Committee. Clinical practice guidelines: depression in young people. Canberra: NHMRC, 1997.

© 1999 Medical Journal of Australia.