Addressing the Increasing Mental Health Distress and Mental Illness Among Young Adults in the United by articles

REVIEW ARTICLE

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Addressing the Increasing Mental Health Distress and Mental Illness Among Young Adults in the United States Mary F. Brunette, MD,* Matthew D. Erlich, MD,† Matthew L. Edwards, MD,‡ David A. Adler, MD,§ Jeffrey Berlant, MD, PhD,|| Lisa Dixon, MD,¶ Michael B. First, MD,# David W. Oslin, MD,** Samuel G. Siris, MD,†† and Rachel M. Talley, MD‡‡

Abstract: Recent surveys show rising numbers of young people who report anxiety and depression. Although much attention has focused on mental health of adolescent youth, less attention has been paid to young people as they transition into adulthood. Multiple factors may have contributed to this steady increase: greater exposure to social media, information, and distressing news via personal electronic devices; increased concerns regarding social determinants of health and climate change; and changing social norms due to increased mental health literacy and reduced stigma. The COVID-19 pandemic may have temporarily exacerbated symptoms and impacted treatment availability. Strategies to mitigate causal factors for depression and anxiety in young adults may include education and skills training for cognitive, behavioral, and social coping strategies, as well as healthier use of technology and social media. Policies must support the availability of health insurance and treatment, and clinicians can adapt interventions to encompass the specific concerns and needs of young adults. Key Words: Young adult, depression, anxiety, social media, climate, stigma (J Nerv Ment Dis 2023;211: 961–967)

wo US population-based surveys and two national surveys of college students have shown increases in distress and mental illness among young adults (ages 18 to 24 or 30 years, with definitions varying among studies) over the past 10 years (Substance Abuse and Mental Health Administration, 2021; Duffy et al., 2019; Villas-Boas et al., 2023). Although extensive research and publicity have focused on adolescent youth (ages 12–17 years) (American Academy of Pediatrics, 2021; Askari et al., 2023; Department of Health and Human Services Office of the Surgeon General, 2021; Madigan et al., 2023; Weinberger et al., 2018), little attention has been paid to young people's mental health as they transition into adulthood. Normal young adulthood is a critical period involving ongoing brain maturation and psychosocial change, with rapidly increasing independence, expanding roles in work and romantic relationships, and waxing and waning need for support from parents, family, and other caregivers. This article examines recent trends in mental health among US young adults, potential contributors to worsening mental health in this age group, and strategies to address mental health among young adults in the current *Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; †Department of Psychiatry, New York State Psychiatric Institute/Columbia University Vagelos College of Physicians and Surgeons and New York Presbyterian, New York, New York; ‡Department of Psychiatry, Stanford University, Palo Alto, California; §Department of Psychiatry, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts; ||Canyon Manor Mental Health Rehabilitation, Novato, California; ¶Columbia University Vagelos College of Physicians and Surgeons and New York Presbyterian, New York, New York; #Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons and New York Presbyterian, New York, New York; **Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, Pennsylvania; ††Department of Psychiatry, Donna and Barbara Zucker School of Medicine at Hofstra/ Northwell, New York, New York; and ‡‡Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Send reprint requests to Mary F. Brunette, MD, Geisel School of Medicine, Dartmouth College, Hanover, NH. E‐mail: Mary.f.brunette@hitchcock.org. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/23/21112–0961 DOI: 10.1097/NMD.0000000000001734

era. We emphasize longitudinal research and meta-analyses including young adults aged 18–30 years where possible.

TEN-YEAR TRENDS IN YOUNG ADULT BEHAVIORAL HEALTH DISTRESS, DIAGNOSES, AND SERVICE UTILIZATION The prevalence of mental distress and/or depression has been increasing in the United States over many years (e.g., Compton et al., 2006). Recently this rise has taken place mostly among adolescent youth and young adults. The National Survey on Drug Use and Health (NSDUH) and the US Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (BRFSS) survey (Substance Abuse and Mental Health Administration, 2021; Ivey-Stephenson et al., 2022; Villas-Boas et al., 2023) are nationally representative surveys providing annual estimates of mental illness prevalence and treatment use in the US civilian, noninstitutionalized population. These surveys demonstrated a disproportionate steady rise in mental illness, depression, and suicidality among 18- to 24-year-olds compared with other adults over 2011 to 2021. For example, as shown in Figure 1, the rates of reporting past year major depressive episode (MDE) with impairment rose from 5.2% to 13.3%, among this group, over a 100% increase in this group compared with a 10% to 27% increase in other adult age groups across the 10-year period. Among randomly selected college students from two large national surveys, rates of depression, anxiety, suicidal thoughts, and suicidal behaviors similarly doubled (Duffy et al., 2019). Researchers have examined and discussed whether the increase in major depression among adolescents is a cohort effect specific to the shared experiences among people born in a specific time period, or time period effect, reflective of a change in environment that could be influencing the risk of depression for all adolescents in the United States regardless of age (Askari et al., 2023). Either birth cohort effect or time period effect on mental illness in adolescent youth could translate to an increasing rate of mental illness in young adults as those adolescent individuals transition into young adulthood. Data from the NSDUH indicate that 47% of people with any mental illness received mental health treatment in 2021 (Substance Abuse and Mental Health Administration, 2021), up from 41% reported in the 2001–2002 National Comorbidity Survey Replication report (Wang et al., 2005). Among adults with MDE and impairment, young adults were less likely to report having received treatment than the older age groups (56.7% for ages 18–25 years vs. 66.6% for ages 26–49 years and 71.8% for ages 50+ years). Of note, this survey also indicated that individuals identifying as Black, Hispanic, and Asian were less likely to report receiving mental health services compared with those identifying as White. Using these NSDUH data, the Office of the Assistant Secretary for Planning and Evaluation reported an increase in unmet need among young adults and indicated that the US mental health treatment system “may not have sufficient capacity to address current rates of treatment need” (Bouchery, 2021). Factors contributing to this include a number of social determinants, the COVID-19 pandemic, the pervasiveness of social media, and destigmatization of emotional symptoms.

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FIGURE 1. Prevalence of MDE 2011–2021 among adults: estimates from NSDUH.

SOCIAL DETERMINANTS OF HEALTH AND CLIMATE CONCERNS Greater severity of mental health symptoms is reported by those experiencing financial and other stressors related to social determinants of health (Kim and Hagquist, 2018a, 2018b). Although US poverty has declined (USAFacts, 2023), the gaps in income between upper-income and middle- and lower-income households are rising and the share of wealth held by middle-income families is falling (Horowitz et al., 2020). Thus, a greater number of young adults overall, and particularly those with lower income and those who identify as a minority, may experience such stressors or be concerned about experiencing these stressors in their futures. For example, student debt has become a greater burden and impediment, especially for lower-income individuals pursuing further education, and the availability and cost of housing have worsened over the past decade. Climate change causes events in communities that may disrupt conditions and resources that support good mental health (i.e., socioeconomic, cultural, environmental, among others) while at the same time creating stressors such as heatwaves, massive storms and floods, or water insecurity that may compound other sources of stress (Lawrance et al., 2022). Studies have demonstrated associations between rising temperatures and poor mental health outcomes, including suicide, hospital admission for mental health symptoms, and self-reported psychological distress (Lawrance et al., 2022). Beyond these disrupting events that compound negative social determinants of health, young people may have strong concerns about climate change, or “climate anxiety,” which includes an array of experiences or mental health symptoms (Thomas et al., 2022). In a 10-country survey of 10,000 youth and young adults, 84% of surveyed young people reported they were moderately, very, or extremely worried about climate change (Hickman et al., 2021). A review of 26 studies supports the consistency of findings on concerns but not on a relationship between concerns and poor mental health (Ramadan et al., 2023). Although the timing of the increase in these concerns appears to overlap with the increase in mental illness, it is unknown to what extent such concerns have contributed to the disparate rise in symptoms of mental illnesses (Dumont et al., 2020; Ma et al., 2022).

ROLE OF THE COVID-19 PANDEMIC In contrast to the dramatic increase in the mental health needs of youth during the COVID-19 pandemic, the mental health needs of young adults appeared to have increased less dramatically. A recent meta-analysis of 137 pre-post studies found that depression symptoms worsened slightly when all studies were included (0.12, 0.01 to 0.24) (Sun et al., 2023); however, examination of the two studies of young adults showed no change. A subgroup analysis of the studies of university students showed a small worsening of depression (26 studies;0.14, 0.01 to 0.26) (Sun et al., 2023). Shorter-term longitudinal research documented first rising and then falling depression and anxiety (Jia et al., 962

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2021). Pandemic and related restrictions were associated with reductions in physical activity and increases in phone use as well as increases in depression and anxiety symptoms among college students (Mack et al., 2021). During this time, housing and financial stress, lower social engagement or support, and lower family functioning (Garcia Colato et al., 2022; Généreux et al., 2021; Kreski et al., 2022; Wiedemann et al., 2022) were also associated with worse mental health symptoms or psychological distress as people coped with the dramatic pressures of job instability, remote work and school, social isolation, and functioning in home environments not designed for the multiple requirements of that period. Longitudinal research during the resolution of acute pandemic challenges showed return to previous levels of symptoms (Jia et al., 2021); specifically, these newly emerged mental health symptoms returned to prepandemic levels (Graupensperger et al., 2022). During the pandemic, the provider workforce experienced significant challenges, and capacity for mental health treatment rapidly shifted to telehealth (Aymerich et al., 2022; Stefanatou et al., 2022). Telehealth facilitated care during this period without clear negative effects (Ainslie et al., 2022; Galvin et al., 2022), and telehealth mental health care was perceived more positively than in-person care by some, including college students (Cohen et al., 2023; Michaels et al., 2022). Acceptance of telehealth delivery of care appears to be persisting. Even with expansion of telehealth, treatment capacity may have shrunk in the past few years for a variety of reasons (e.g., pandemic-related changes in work environments, work-life balance, and burnout) (Gourret Baumgart et al., 2021; Johnson et al., 2021; Kane et al., 2022). Moreover, shifts in the mental health system that began in the pandemic have continued, with worsening access to outpatient and inpatient care. It remains unclear across heterogeneous US systems how recent changes will impact care for young adults (Erlich et al., 2022).

SOCIAL MEDIA, INFORMATION TECHNOLOGY, AND ONLINE INFORMATION The period of increasing self-reported mental illness among young adults corresponds with the time period of >85% saturation in smartphone and social media use by young and middle-aged adults since 2012 (Vogels, 2019). By 2021, the Pew Research Center found that 70% of adults aged 18 to 29 years used Facebook, 65% used Snapchat, 71% used Instagram, 48% used TikTok, and 42% used Twitter (Auxier and Anderson, 2021); thus, social media use is normative in US society, varying and complex (Masciantonio et al., 2021). Based on a substantial amount of research, albeit with inconsistent findings (Valkenburg et al., 2022), the US Surgeon General recently announced that use of social media is detrimental to US youth (US Department of Health and Human Services Office of the US Surgeon General, 2023). However, its impact among young adults is not well studied. In 2021 and 2022 surveys, 35% and 37% of 18- to 29-year-old young adults indicated that they believed social media had a negative © 2023 Wolters Kluwer Health, Inc. All rights reserved.

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Mental Illness Among Young Adults

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impact on their mental health, whereas 44% to 39% were neutral and 22% indicated a positive effect (Harvard Kennedy School, Institute of Politics, 2021; Harvard Kennedy School, Institute of Politics, 2022). This range of perspectives may be explained by findings that specific styles of cognitive and affective responses to content in social media predicted depression over time (Brimmel et al., 2023). Longitudinal studies can best assess whether there is a causal relationship between social media use and mental health, but few have been completed. An important study used longitudinal data from the nationally representative Population Assessment of Tobacco and Health survey. This analysis included 5,114 US adolescent youths followed over 4 years into young adulthood and used multigroup latent growth curve models. The study demonstrated that frequent social media use was associated with poorer subsequent mental health over time, with different trajectories for boys and girls (Lee et al., 2022). Since the pandemic, there appears to be increased societal acceptance of social media and the use of technology replacing in-person interactions (e.g., applications that allow for young people to “hang out” online rather than in person, or streaming a movie by themselves rather than going with others to a theater), leaving more people vulnerable to negative impacts of technology and social media on mental health. Another question is whether frequent smartphone use in general is detrimental to mental health. Cross-sectional research has shown an association between problematic smartphone use and poor mental health (Sohn et al., 2019), but prospective, longitudinal research, needed to understand causality, has provided mixed results (Brailovskaia et al., 2022, 2023; Dissing et al., 2021, 2022; Vernon et al., 2018). Smartphone use may impact mental health via frequent exposure to news in general and news with distressing, sensational, or politically divisive content in particular. A recent survey found that 46% of young adults indicated that news negatively impacted their mental health (Harvard Kennedy School, Institute of Politics, 2022). Easy and frequent access to online information and news may create greater awareness of inequities that may contribute to stress and poor mental health. In support of this hypothesis, a longitudinal ecological momentary assessment study of college students documented increases in mental health symptoms during and following the time of the news of the murder of George Floyd (Mack et al., 2021). Analyses of BRFSS survey data and emergency department visit data matched with geography of police killings of unarmed Black people demonstrated regional worsening of mental health specifically among Black Americans after these events (Bor et al., 2018; Das et al., 2021). The relationship between media exposure to frightening events and mental health symptoms may feed on itself. A national longitudinal study demonstrated that level of media exposure to mass violence events was associated with increased symptoms, and high media exposure predicted increased media consumption of future mass violence events and further symptoms (Thompson et al., 2019). In addition, research has shown that watching news conveyed with high affect was significantly related to mental health-related search behavior, suggesting that sensationally presented news likely further negatively impacts the population's mental health (Lekkas et al., 2022). The ability of technology and social media to rapidly spread and inundate viewers with social, medical, and traditional information and misinformation may lead to misunderstanding, confusion, and social contagion of concerns (Yeung et al., 2022), which may exacerbate or contribute to poor mental health or mood and anxiety disorders.

larity” during this period in America has seen new attention (Frances, 2013; Kendler, 2016; Paris, 2015). Antistigma campaigns, such as the National Alliance on Mental Illness' “stigmafree” campaign (Clement et al., 2015; McLaren et al., 2023) and the Mental Health First Aid program (Kitchener and Jorm, 2008), were designed to increase knowledge about mental illness, decrease stigma, and increase treatment seeking. One consequence may be increasing endorsement of mental illness symptoms among young people. A recent longitudinal study provides some evidence that young people now harbor less stigma about depression than in the past (Pescosolido et al., 2021). In addition, one untested hypothesis is that the promotion of access to helplines (including the new 988 hotline) staffed by trained lay people and use of easier access online counseling may have led to a reduction in diagnostic stringency. Another possible result of reduced stigma is greater discussion and possible “contagion” of mental health symptoms among social contacts. Social contagion among young people and its interaction with treatment-seeking behaviors and resulting mental health diagnoses have not been fully evaluated in the current setting of established social media behaviors, lower stigma, and access to helplines and online treatment (Haltigan et al., 2023).

DESTIGMATIZATION, CONTAGION, AND INCREASED REPORTAGE OF SYMPTOMS

Although addressing broad issues such as social inequities and climate change is outside the scope of this discussion, helping young people cope with these issues is an important strategy that may prevent the development or worsening of mental health problems. Public health education and improved coping skills training should be provided in online venues used by young people, as well as in college and university settings. Such education should support use of physical exercise, sleep hygiene, effective cognitive and behavioral coping strategies, social

Antistigma campaigns and other cultural trends have increased awareness of and acceptability of symptoms of depression and anxiety. It is possible that signs and symptoms of distress, such as worry and fatigue, are perceived as signs of mental illness. The cultural interpretation of symptoms, diagnostic flexibility, or diagnostic “popu-

SUMMARY OF CONTRIBUTING FACTORS In sum, the increasing prevalence of poor mental health among young adults is likely the result of multiple factors: increased awareness and stress related to social determinants of health and concern about climate change; impact of frequent exposure to social media, information, and distressing news via personal electronic devices; and potential increased reporting and diagnosis based on increased mental health literacy and reduced stigma. The exact contributions of these factors are still unclear and require further research. Nevertheless, the increasing mental health distress and diagnoses among young adults call for action by public health and mental health systems, providers, and policymakers. Although recognition of the increase in mental distress and illness among young adults is critical regardless of identifying the exact causes, interventions can nonetheless be informed by an understanding of these factors.

PREVENTION AND INTERVENTION STRATEGIES TO ADDRESS MENTAL HEALTH IN YOUNG ADULTS A two-pronged approach can be implemented and built upon. First, strategies to prevent or mitigate causal or risk factors are essential. Second, screening, assessment and treatment can be adapted to encompass the changing world in which we live. In the prepandemic period, access to mental health services, improving resources, destigmatizing psychiatric diagnoses, and implementing preventative strategies were at the forefront of prevention and promotion of recovery. In the current era, it appears there is less trust in science and medicine (Adekunle et al., 2023; Adler et al., 2021; Fridman et al., 2020), but there is improved access to care through technology and an increased focus on mental health (US Department of Health and Human Services Office of the US Surgeon General, 2023; Andino et al., 2023; Talley et al., 2021). The current environment can support prevention as well as disciplined comprehensive assessment and effective intervention for young people experiencing this wave of mental health distress and mental illness.

PREVENTION AND MITIGATION OF CAUSAL FACTORS

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skills and supports, and healthy use of technology and social media. Hundreds of readily available and appealing smartphone apps can provide mental health education and skills training (Camacho et al., 2022). Because young people need support from families to garner, implement, and sustain healthy coping skills and habits, educating families about such strategies may also be important. For people with excessive or problematic use of technology or social media, recent research supports the efficacy of educating young people to reduce smartphone or social media use to reduce depression symptoms and/or improve life satisfaction (e.g., Tromholt, 2016). A simple educational intervention was studied in a recent controlled trial among mostly adult university students (mean age, 26 years) in Germany. Brief instructions to both reduce smartphone use and increase exercise resulted in changes in these behaviors as well as reduced mental illness symptoms and increased happiness (Brailovskaia et al., 2022). Mass media public education regarding nighttime smartphone use has similarly been shown to reduce smartphone use and improve sleep hygiene broadly across a population (Andersen et al., 2021). Whether changing smartphone use over time has a lasting, meaningful impact on decreasing severity of illness is not known. More broadly, given concerns about social inequities, a logical assumption would be that addressing and mitigating such inequities could reduce mental health symptoms. Although addressing many of the social determinants of health requires a societal commitment to support policy change, changes such as universal access to health insurance could have large impact. Concerns about cost are a common reason people do not seek treatment. For example, just over half of young adults with recent depression surveyed from 2011 to 2019 believed they could not afford mental health treatment (Lu et al., 2022). Young people who were not students were most likely to have concerns about cost and insurance (Cadigan et al., 2019). For young adults, access to parental insurance up to the age of 26 years and expansion of Medicaid for people living in poverty are important strategies to maintain and improve access to behavioral health care in the United States by ensuring that young people have a way to pay for it (Olfson et al., 2018). Increasing insurance access to individuals and families is essential to increase assessment, evaluation, and treatment. For example, in Medicaid expansion states post–Affordable Care Act implementation in 2012, coverage for low-income residents increased overall from 30.6% in 2012 to 2013 to 46.2% in 2014 to 2017, whereas in nonexpansion states, coverage made less robust gains, increasing from 18.1% to 21.5% in the same time period (Olfson et al., 2020; Zuvekas et al., 2020). Coverage in expansion states was associated with increased use of care and decreased mental health distress (Margerison et al., 2020; Sommers et al., 2016) as well as with decreased concern about inability to pay or delaying care due to cost (Miller and Wherry, 2017; Sommers et al., 1988). However, access to insurance is not enough to encourage most young adults to access treatment (Olfson et al., 2018). While state and federal policy should continue to support payment for in-person and telehealth care for young people and their parents, additional efforts are needed to encourage use of effective interventions in this group.

ASSESSMENT AND TREATMENT Healthcare providers need to promote mental health services in a variety of settings and venues that are accessible and understandable to young people while ensuring that access is broad enough to be inclusive of people of color and those with limited resources. Young people stress the importance of access to care that is convenient and offered in a welcoming setting (Persson et al., 2017). Not knowing where to go was a common reason young adults stated they did not seek treatment, and this reason, not surprisingly, had an additional racial and economic divide. For example, lack of access was more common among people who identified as Asian/Native Hawaiian (53.5%) and Hispanic (40.4%) than white (29.4%) (Lu et al., 2022). For those able to pursue higher education, 964

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university-based mental health services are necessary, but access to care is highly variable in these settings (Osborn et al., 2022). To combat stigma (Clement et al., 2015; Lu et al., 2022), treatment should be encouraged through public health campaigns to reduce stigma and increase access to care, as young adults are still less likely to seek treatment than older age groups. Adding inspiring video of personal stories to educational campaigns addresses social norms and has the potential to improve the ability of campaigns to increase help-seeking behavior (Amsalem et al., 2022). Normal young adult development involves rapidly increasing independence and expanding roles in work and romantic relationships with waxing and waning need for support from their family. Clinicians must be familiar with the normal developmental concerns of young adults to identify whether distress and symptoms signify a diagnosable mental illness and, once identified, to translate evidence-based practices in an appealing and effective manner. In addition to more traditional assessment of individual and family history of symptoms and behaviors related to behavioral health conditions, the social and family history should incorporate assessment of social determinants of health, use of technology, social media, and online behavior, as well as concerns about environment and social inequities. Interview templates should cover use of technology and attitudes regarding current social and environmental issues as part of routine evaluations. To address social, cultural, equity, and climate concerns, clinicians can begin by validating concerns and distress, developing social supports by connecting young adults to others with similar concerns, and fostering resilience through evidence-based behavioral interventions, through evidence-based behavioral interventions (e.g., Individual Resiliency Training, a psychotherapeutic approach for young people with first episode psychosis (Mueser et al., 2015)).

CONCLUSIONS Over the past 15 years, mental health distress and illness have increased among young adults in the United States. Multiple factors may have contributed, including the following: increased awareness and stress related to social determinants of health and concern about climate change; impact of frequent exposure to social media, information, and distressing news via personal electronic devices; and potential increased reporting and diagnosis based on increased mental health literacy and reduced stigma. The COVID-19 pandemic may have temporarily exacerbated mental illness symptoms and treatment availability. Strategies to prevent or mitigate causal or risk factors may include improved education and skills training to support use of physical exercise, sleep hygiene, effective cognitive and behavioral coping strategies, social skills and supports, and healthy use of technology and social media. Access to professional treatment through insurance payment for in-person, telehealth, and digital services can be supported with ongoing policies. Screening, assessment, and treatment can be adapted to encompass the specific concerns and needs of young adults. Increased attention to investigating the causes of mental health distress and mental illness in young adults and interventions to improve mental health in this age group are clearly warranted.

DISCLOSURE All authors are members of the Psychopathology Committee, Group for Advancement of Psychiatry, New York, NY. Disclosures: David A. Adler, MD, is a cofounder of Health and Productivity Sciences who has no assets and has been an investigator on research grants from Janssen Pharmaceuticals. The remaining authors have no conflict of interest. © 2023 Wolters Kluwer Health, Inc. All rights reserved.

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