Youth Mental Health Should Be a Top Priority for Health Care in Canada

By: Ashok Malla
Societal Perspective
‘Youth’, the age group 12 to 25 years, encompasses early adolescence and emerging adulthood.7 Adolescence is a period of social and developmental turmoil as youth try to negotiate several challenges, including transition into multiple social roles from the limited and dependent roles of childhood and simultaneous formation of distinct identities. Key in mental health is the concept of transitional youth, the age group starting in adolescence and moving into adulthood. ‘Emerging adulthood’ is a relatively recently recognized phenomenon of delayed social and personal independence observed among young people8 that has some implications when discussing youth mental health.
From this broader perspective, arguments to support attention to youth mental health (YMH) and addictions run to the very core of the social and economic well-being of all societies.9 The contribution to loss of gross domestic product (GDP), resulting from mental health and addictions, is reportedly on par with cardiovascular disorders.4
Unlike physical health problems, most (75%) mental disorders have their first onset before the age of 25.10 Mental disorders surge during the transition between childhood and emerging adulthood10 and have long-lasting health, social, and economic impacts on individuals, their families, and society.11–13 While most noncommunicable medical disorders usually begin later and have their highest prevalence in or after middle age, mental health problems in youth start early and compound the longer-term picture of the former through comorbidity and shared risk factors.14–16
Older generations at times express clichéd concerns about young people’s capacity to manage the future (concerns expressed about Generation X and more recently about the Millennial Generation). There is no real basis for these concerns; every society relies on its youth to maintain continuity of the economic and social order. Millennials, for example, make up a substantial proportion (1 in 6) of the workforce today.17 In high-income countries like Canada, changing social demographics help to focus the challenge. The relatively small proportion of the population (15%-20%) under 25 years of age18 will need to sustain an increasingly aging population, so the health of the youth, crucially dependent on their mental health, has never been more important. In Indigenous communities in Canada, a higher proportion of the population is under 25 years old (40%-50%),19 and they experience higher rates of mental health problems with even more limited access to care than non-Indigenous youth.20 Attending to the physical, mental, and social development of children and youth is vital to survival of Indigenous communities in Canada. Not doing so is not just a lost opportunity for social and economic development but also a potential societal disaster.
Early onset of mental illness and delay in or lack of access to adequate interventions frequently result in a downward spiral of disadvantage and suffering for young people and their families, leading eventually also to serious leakage from economic and societal or social development. Youth with untreated mental illness are likely to miss opportunities for education and employment, reflected in the claim that mental disorders represent 60% to 70% of disability-adjusted life years (DALYs) among young people.21 Given the nature of DALYs, the future impact is probably an underestimate. Investment in prevention and early intervention makes great economic sense.22
Scientific Perspective
The incidence, prevalence, and distributions of mental health problems are not matched by the current availability and efficacy of care. Formal studies23–25 show that 20% of youth experience symptoms of mental disorders and at least 50% of these warrant intervention.26,27 Depression and anxiety, the 2 most common disorders, most often have their onset in childhood and adolescence, while schizophrenia first appears in the postpubertal period. Anxiety and impulse-control disorders reach their peak incidence relatively early, with 75% of cases appearing prior to the age of 21 and 15 years, respectively.24,28 Major mental disorders such as major depression, bipolar disorder, and psychotic disorders that begin early mostly continue through adult life.
Given their age at onset of such disorders, delays and missed opportunities for intervention are alarming. Such long delays for first intervention extend from 1 to 2 years for psychoses, 6 to 8 years for mood disorders, and 9 to 23 years for anxiety disorders.24,29 Delays result in poorer outcomes when treatment is eventually provided. Treatment delay in cases of psychosis has a long-lasting effect on clinical as well as social outcomes30–32; early intervention services that combine state-of-the-art treatment interventions and reduction of delay in treatment through open and rapid access in psychosis reduce many of these negative consequences, including suicide.33–37
The evidence for effectiveness of early intervention services is well established 37 and is beginning to extend to interventions at presyndromal stages in those regarded as being at clinical high risk for psychosis. 37 Delays in intervention for even milder disorders or subthreshold symptoms may complicate future presentation of mental disorders as often untreated earlier stages progress to more severe and complex problems through increasing functional deficits, comorbidity of substance abuse, or simply progression of underlying pathological phenomena. 38 Delayed treatment can be associated with dire consequences that are difficult to attribute directly to the actual delays—suicide, traffic accidents, missed employment opportunities, crime, and poor physical health.
The Canadian Community Health Survey-Mental Health confirms a high incidence and prevalence of mental health problems among youth, as well as poor or late access to care.39 Suicide is the second cause of death among 15- to 24-year-olds 40 in Canada; this is the third highest youth suicide rate in the industrialized world. 41 Among Indigenous men and women, suicide rates are respectively 5 and 7 times higher than the Canadian average.42,43
The recent crisis facing the country, with deaths from drug overdoses of fentanyl reaching epidemic proportions, has also largely involved youth under 25 years of age.44,45
Recent work in developmental neuroscience indicates that adolescence is a crucial developmental period. During the first 3 decades of life, brain development and maturation occur through dynamic and highly complex neural remodeling, involving changes in structure and connectivity.46–50 This provides the backdrop for enhanced vulnerability, during which environmental changes can disrupt behavioural adjustments and result in what we understand as mental disorders. Relatively small deviations in the developmental trajectories of normal brain development may provide the opportunity for increased risk for these disorders during this period.51
Youth mental health has a bearing on the rest of health care. Individuals with mental disorders have a shorter life expectancy than do members of the general population; they have increased risk of later, as well as high comorbidity with concurrent, physical health problems. Youth mental health problems act on physical health through several mechanisms. Mental health problems are associated with higher rates of smoking and substance abuse, nutritional disorders (like obesity), and sexually transmitted diseases. These comorbid risks are themselves associated with risk of health problems like diabetes, cardiovascular and respiratory problems, cancer, and dementia.52–58 In addition, most mental disorders and many non-communicable medical disorders (like diabetes, coronary artery disease) share many environmental risk factors, including childhood and intergenerational trauma,59 social and material deprivation,60 parental substance abuse,61 and parental history of mental disorders.62
Current Services Are Inadequate for Mental Health Problems of Youth
Our overall response to youth mental health has been inadequate and inappropriate.
The challenges continue: high incidence and prevalence, extreme delays in appropriate care even in the face of suicidal behaviour, high rates of disengagement even after accessing services,63 the large institutional and biomedical nature of care available and high use.