The Daily - Inside the Adolescent Mental Health Crisis

Episode Date: August 30, 2022

This episode contains discussions about suicide, self-harm and mental health issues.In decades past, the public health risks teenagers in the United States faced were different. They were externalized risks that were happening in the physical world.Now, a new set of risks has emerged.In 2019, 13 percent of adolescents reported having a major depressive episode, a 60 percent increase from 2007. And suicide rates, which had been stable from 2000 to 2007 among this group, leaped nearly 60 percent by 2018.We explore why this mental health crisis has become so widespread, and why many people have been unprepared to handle it.Guest: Matt Richtel, a correspondent based in San Francisco for The New York Times.Background reading: Depression, self-harm and suicide are rising among American adolescents. The coronavirus pandemic intensified the decline in mental health among teenagers but predated it.Increasingly, anxious and depressed teens are using multiple, powerful psychiatric drugs, many of them untested in adolescents or for use in tandem.For more information on today’s episode, visit nytimes.com/thedaily. Transcripts of each episode will be made available by the next workday. 

From the New York Times, I'm Michael Barbaro. This is The Daily. Today, why the mental health crisis afflicting America's youth has become so widespread, and why seemingly everyone has been so unprepared to handle it. has been so unprepared to handle it. I spoke with my colleague, Matt Richtel, about what his investigation has found. It's Tuesday, August 30th.

Matt, for the past couple of years, you have been exploring a topic that, especially throughout the pandemic, has become a lot more visible to people, which is that kids, and especially teenagers in the United States, are in the throes of a mental health crisis. So tell me about that reporting. Yeah, a couple of years ago, we noticed that young people are dealing with mental health distress. And we started to look into the numbers to ask what's really going on. In 2019, Michael, 13% of adolescents reported having a major depressive episode. And that was a 60% increase from 2007. Suicide rates, which had been stable from 2000 to 2007 among this group, leapt nearly 60% by 2018. So we started with a basic set of facts. Curiously, this was not the set of facts alone that told us we had something significant to investigate.

What do you mean? Well, there was a separate set of data. When I was an adolescent at the risk of dating myself in the 80s, the public health risks were very different. They were binge drinking, drunk driving, cigarette use was still very high, teen pregnancy and early experimentation with sex. these were known as externalized risks. They were happening, say, in the physical world. The new set of risks are internalized risks. There had been a transformation in the kinds of risks facing adolescents. And so my editors were gracious enough to give me enough time to try to unpack the reasons why, and we've been at it for a couple of years.

The nature of the threats to young people have changed. They've become not external, but literally internal. Yes. So the question became not only why have the mental health disorders spiked, but why did it catch us off guard? How did this sneak up on us and what the heck do we do about it? So how did you go about answering those questions of not just how we got here, but why it seems we're so unprepared for it? I started by talking to adolescents and their parents. I talked to scholars parents. I talked to scholars, and then I talked to the clinicians, the pediatricians, the people on the day-to-day

front lines dealing with a lot of this stuff. Okay, Matt's calling me. Hey, Matt, how are you, honey? I am well. How are you? And what did you learn from the pediatricians? In talking to pediatricians around the country, I lucked out in meeting Dr. Melissa Dennison. It's nice to see a smile on your face. There's a smile on my face too. Dr. Dennison grew up in a poor rural part of Kentucky. I was the daughter of farmers. And became committed to becoming a pediatrician. I chose to be a pediatrician

because pediatricians were most like me. The most family-oriented and in my opinion nicest people. You know they felt like and I feel like children are the most important people around. She wound up in this town of Glasgow, which is about 40 minutes from the farm where she grew up. And when she got into the pediatrician business in the 90s, she was dealing with what we think of as old school pediatrician issues. Pediatricians at that point were pretty much infectious disease doctors. Broken bones and bruises. A lot of ear infections, a lot of pneumonia. Struck throats and runny noses. A lot of rashes. Antibiotics. The main prescription was amoxicillin. Parents felt like that would take care of anything.

And then we did a lot of well child care. We did a lot of immunizations, those kind of things. And then we did a lot of well child care. We did a lot of immunizations, those kind of things. But now in the last, say, decade, increasingly, she's seen those alongside a different set of issues. So for the last 10 to 15 years, pediatricians were told that they should be able to handle bread and butter attention deficit disorder. But on top of that, we've also had to take care of a lot of children with anxiety, depression. Issues around mood and attention. You know, she started to see people cutting themselves and people who profess to be suicidal. No, I never saw anybody cutting

themselves back in 1990. And I didn't have teenagers come in and say, I think I'm anxious. I think I need anxiety medicine. And of course, today I see it all the time. And it really sunk into her that her practice had to change, and it was changing. Right. I mean, what do you do when you're a pediatrician who has trained for the flu and for chickenpox, and suddenly you have someone coming in saying, I'm having thoughts about taking my own life? What does she say about that? When I did my residency, we maybe had a month of child psychiatry. The first thing she says is, this is not what I trained for. You were kind of told, you don't really need to know that much about it because if you get into a pinch, you're going to be able to send your child to a child psychiatrist. Just concentrate on the other things.

She's trying to come up to speed with these issues around her. And that was partly because there were not great resources around her to help these young people. In this community, we have two child psychiatrists that are located about 40 minutes from here. At this point, they pretty much do not take Medicaid. They take private insurance. And the wait to get in to see them is sometimes three to four months long. As much as you want to think of rural poor Kentucky as the place that wouldn't have these mental health services, she's consistent with what's going on in a lot of places in the country you know so we have done a lot of psychiatry just because there's no place for them to go you know nowadays you know

a half to three-fourths of what I do are anxiety medicines attention deficit medicines those kind of things so she becomes the de facto frontline provider for a bunch of really complicated mental health issues. You know, I would just love to be able to get a child psychiatrist to see the ones that I don't feel comfortable with, helping me know which medicines would work better, help me try to tweak some things that really help these people out. tweak some things to really help these people out. So Matt, when we think about why we were caught off guard when it comes to this mental health crisis among young Americans, it seems pretty clear that a big reason why is that the primary medical point of contact for young people, pediatricians, were just not trained to handle this. Yes. And then in 2019, this fairly remarkable statement comes out from the American Academy of Pediatrics. And I just, I want to quote it because it's so powerful.

Please. And I wrote, quote, mental health disorders have surpassed physical conditions, mental health disorders have surpassed physical conditions, unquote, as the main source of impairment and limitation among adolescents. From the traditional threats you mentioned of alcohol, pregnancy, to internal threats of mental health. Correct. And then this report also says, quote, pediatricians need to take on a larger role in addressing mental health problems, and says, quote, yet the majority of pediatricians do not feel prepared to do so. So just three years ago, the Professional Association of Pediatricians is saying, we're not prepared, and we know we're in the middle of a crisis. That's right, Michael. And imagine if the doctors are playing catch-up here, what is it like for the young people, the adolescents, the teens experiencing this pain saying, what the heck is going on?

We'll be right back. Matt, you said that you have spoken to a lot of kids themselves about the state of their mental health and about their lack of, for lack of a better word, readiness to deal with it. So what have you learned from those conversations? Yeah, it's where I've learned the most. And actually, one of the young people, C, gender non-binary young person in Utah, I have been talking to for the better part of three years. I was born in December of 99. So I'm a nineties baby. Tell me about C story.

C grew up in a comfortable family, loved. I was surrounded by, you know, love and running around in my yard and having a pretty, pretty great childhood. running around in my yard and having a pretty, pretty great childhood. But C started to feel restless and sad, depressed, anxious. The first time I kind of had an inkling that what was happening to me was not supposed to be happening to me and was not, you know, just a healthy part of growing up was when I started experiencing really intense physical symptoms of depression, I would, you know, throw up and be, you know, have sweats and I would shake and I would have really awful pain in my

chest and in my neck. And she starts experiencing these feelings as early as third grade and they, they get very intense. It hurt really, really bad. And it is exhausting. It's physically and mentally exhausting to be in that amount of pain constantly and to not have like really a direct answer about why it's happening. It's not like you have the... Now, third grade seems extremely young for someone to be afflicted with this level of mental pain. Yes. with this level of mental pain.

Yes. And it actually speaks to a much larger, more pervasive issue, which is puberty. So I hit puberty so crazy early and I was still in elementary school and suddenly my brain is, you know, working like 20 times faster on the dark crap. You know, suddenly everything is like a million times harder. Puberty is hitting earlier by a lot as compared to even a century ago.

Girls had their first menstruation at around the age of 14 in 1900. Now it's around 12. Boys are following a similar pattern and it had been dropping even before that. This is a very significant point in our conversation. Well, explain that. Why is that significant a few years earlier onset of puberty to the mental health of young people? So we think of puberty or we tend to generalize it as something having to do with sex or reproduction, but really a lot of it's happening in the brain. That's where a lot of the action is. The brain is preparing this creature to be aware of social information. In fact, to crave social information as a way of figuring out how to fit in to a much more complex world than the one where the child was cared for.

Hierarchy becomes apparent. Competition becomes apparent. Hierarchy becomes apparent. Competition becomes apparent. All this information that a young person was either blind to, didn't see, or didn't care about suddenly becomes vivid. But the rest of the brain has not developed any faster. Parts of the brain that help make sense of the information that is suddenly so stimulating. There's a mismatch here. You've got a neurological mismatch. And the so what of that mismatch depends in no small part on what the environment is like around you. For instance, if you're 150 years ago and you're sensitized to a whole bunch of social information, the mismatch takes less of a toll.

You may have trouble digesting information, but there's less around you and in front of you to make sense of. But what happens when there becomes a cascade of social, hierarchical, competitive information? Got it. Got it. A big thing happening here is that young people are going through puberty faster, and therefore are being overwhelmed with feelings, and they're simultaneously being overwhelmed with stimulation. And I'm guessing that ranges from Instagram to what's ever streaming on Netflix or HBO, and it's leading young people to be very unhappy. Yes, and it's tempting, Michael, to say that this is just social media or a particular app, but it's really the pace of a technologically driven world.

And it comes out in a myriad of ways. Your parents, if you're an adolescent, feeling pressure to have you keep up. The way you are aware of other people's academic and athletic performance, along with all the news events, climate change or shootings or whatever it might be, cascading in at a time your regulatory functions aren't there to help you make sense of how seriously to take what information. So how does this all play out for C, the concept of early pubescence and an environment that's overstimulated? So C does, I guess in a way, perversely what a lot of young people do is look to the internet itself for some comfort,

for some escape. So I got my first iPod Touch first gen when I was probably 10 years old and it was a birthday present. And I was so stoked. C gets an iPod from their grandparents. And they're like, nothing bad is going to happen when we give this 10-year-old an iPod Touch. What could go wrong?

C goes online. And I ended up on social media because... Post pictures of themselves they think are flattering. Mm-hmm. This is a way to feel better about themselves. Because nobody warned me. You know, they tell you about stranger danger, but I was not actively seeking these people out.

I posted a picture of myself, and then people would come to me and harass me. But lo and behold, what happens is what you might imagine. Men begin to send, C terrible, offensive, sexualized images, ask for images from C. C's essentially assaulted and can make no sense of what's happening to them. And I never imagined that just existing would bring so much, you know, negativity and disgustingness into my DMs, but it sure did. So C is feeling terrible, feeling confused, doesn't know how to talk about this. There's no language out there, tries to talk to adults. Nothing seems to work.

C winds up developing a self-destructive coping mechanism, self-harm. C winds up developing a self-destructive coping mechanism, self-harm. I had a pencil in class and I would sit at my desk and I would sharpen my pencil and I would just kind of sit there and dig at my leg with it for all day. And it was addicting and I loved it. And that was probably the first time that I figured out that like a grounding mechanism could be not even pain, but just like any sort of physical sensation outside of the somatic pain of depression was better than just sitting there and dealing with it. C has a number of visits to hospitals as C goes through this, you know, trying to solve it. And in the fact that C is turning to hospitals, they are also representative of an emerging

trend. Over the last decade or so, the number of young people going to emergency rooms for self-harm-related incidents is up 300%. Wow. And not just self-harm, suicidal ideation, symptoms of anxiety and depression, obsessive thinking, rumination, aggression. And remember, this is a place that for a long time was dealing with acute physical injuries, the result of car accidents or, you know, people playing in the park, the concussion, the broken arm. And now the emergency rooms are seeing a massive increase in mental health related conditions.

So when the young people are showing up, the emergency rooms are themselves ill-equipped to deal with mental health issues. This is from the mouths of the ER docs themselves. To one, they say, look, we are trained to deal with the gunshot wound, these terrible acute issues, but then to move people to the next level of care. Right. acute issues, but then to move people to the next level of care. The thing is, this is a mental health issue that by definition in many ways is chronic. And the doctors there are not equipped.

They've never been taught to deal with this. So guess what happens? What happens is young people go in and they wait. Every night in emergency rooms across the country, there are at least 1,000 young people spending the night waiting in a room to get to the next level of care where they can be helped. There are at least 1,000, but as many as 5,000 a night in the U.S. in emergency departments waiting for somewhere to go. So after all this reporting, years now of trying to make sense of all this,

what in your mind are the steps required to make everyone we're talking about here better prepared to handle this crisis? I'm thinking about this from a listener's perspective and imagining that many of them are thinking that the answer might be medication. Right. Over the course of the reporting, I've talked to lots of adolescents taking medication, C, Tuxoloft. Medications are complicated. They can be vital and life-saving when properly prescribed. Experts will also say that they are prescribed in combinations we don't understand for safety and effectiveness. You know, in some ways what they're getting at is that we are prescribing medications in the absence of dealing with two fundamental structural changes that we

have not addressed as a society. One is a neurological mismatch. And the other is the mismatch between the kinds of ailments young people are dealing with and the way society is structured. So whatever we do going forward, while medication may be a part of that conversation, it can't be the final answer. So where does that leave us? Yeah, where does it leave us? leave us. Yeah, or it doesn't leave us. It leaves us at this big idea, I think, recognizing that given the complexity of the world and the early onset of puberty, the massive information coming at young people, we have to do a better job providing the structure that acts partly as the regulatory function of the young person's brain. So what would that look like? Well, there are a few therapies that are beginning to emerge

that are specifically aimed at trying to help young people through these periods of intense emotion when their regulatory functions aren't there, broadly speaking. And there are a number of different options, but broadly speaking, you can think of things like cognitive behavioral therapy, which is a type of therapy that isn't like that Freudian stuff where you talk about your mom and your dad, but as its name suggests, is around behavior and cognition. What am I feeling? What am I experiencing?

And how do I cope with that? Various versions of this aim to help people through these moments of intense emotion, not by saying to them, just calm down, go for a walk. Have you really tried to do your homework? Instead, they try to validate that this actually is a real overwhelming sensibility or feeling or emotion that the adolescent is experiencing, and then take a variety of steps to help move the adolescent out of that place

so that they can begin to consider other options, to consider different coping mechanisms that are less self-destructive, and to ultimately understand that in fact, they were overwhelmed, that this was a temporary state, and that they can come out the other side of it, a more reasoning person, someone who can make sense of this intense emotion that they're experiencing. So therapies that are very practical, but also really, really honor, really honor and respect what these kids are going through. Yes. And that is where we've sort of fallen behind as a society and somewhat understandably, because you can imagine 50 years ago, the answer was, you know, go to your room. You're not paying attention in school. In fact, many of these problems that cropped up in prior generations were seen as like, you know, something wrong

with the kid. It's something wrong with the mismatch. So Matt, is something like cognitive behavioral therapy being more widely adopted if, as you're saying, it seems to be a part of a solution? This goes to the point about how we're behind. We don't have enough therapists in this and in other fields. There's not enough counseling. There's not enough people who are trained. There's not enough families who can afford this stuff. When we get there though, Michael, and I'll sound a bit naive in saying this, I want to give you my chief reason for hope. Could you imagine if people started to have a teen life crisis instead of a midlife crisis,

meaning they learn to cope with difficult emotions and decisions and opportunities and choices earlier on in life, whether that might create a runway for a richer, healthier life going forward. Like, there's an opportunity here. To learn how to deal with really hard stuff, even though it's at a really early age, if we all agree it's important to address it and to teach it. The crisis has forced us to have a learning moment. And I guess in some ways that's what happened for C.

Hmm. You know, people treat you like it's your fault. And then suddenly a doctor came in and told me that I'm going to be okay because you're hurt, but you're not broken forever. You're not just going to wallow in your depression forever. We're not going to let you. And that was the first time that somebody, you know, made it not my fault. C had begun to learn better coping mechanisms,

learn to understand that this thing that's inside of C that maybe was partly genetic, maybe triggered by an environment and an early puberty can be addressed and that C has some control over that situation. So C has navigated this. C has navigated this and C has learned that they must navigate it from here on out.

Well, Matt, thank you very much for all of this. We appreciate it. Michael, thank you so much for having me. I appreciate it. We'll be right back. Here's what else you need to know today. In Iraq, supporters of a prominent Muslim cleric stormed the presidential palace in a series of clashes that left about 12 people dead and highlighted the country's political chaos. The clashes followed an announcement by the Shiite cleric Muqtada al-Sadr that he was retiring from politics.

Sadr won the largest number of seats in Iraq's parliament last October, but failed to form a government. And on Monday, Ukrainian forces said they had launched a military offensive in the country's south, potentially signaling the start of a long-awaited operation to retake a key area from the Russian military. The offensive is focused on Ukraine's Kherson region, whose capital was the first major city to fall to Russian forces when the invasion began. But it's unclear whether Ukrainian forces actually have the capacity to take back the territory. Today's episode was produced by Michael Simon-Johnson and Ricky Nowetzki,

with help from Stella Tan. It was edited by Patricia Willans and Michael Benoit, contains original music by Mary Lozano, original audio from Casey Bracken, Elliot DeBruin, and Ben Laffin, and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Landsberg of Wonderly. That's it for The Daily. I'm Michael Barbaro. See you tomorrow.