Now is the most important time to focus on teen mental health

This June marks the 45th anniversary of the 1976 student uprising in Soweto, where children lost their lives while standing up against the apartheid government for the right to equal education. Decades later, every youth month, a vital question remains: Have we made strides in ensuring that the voice of the youth is truly heard?

In South Africa and across the world, adolescents battle daily for what is a fundamental right - access to mental health support when they need it most. Why is this the case?

The 2016 Lancet commission on adolescent health and wellbeing explains that adolescence is a critical phase for achieving human potential. It's a time of dynamic brain development; one in which the interaction with the social environment shapes the capabilities an individual takes forward into adult life.

"However, it's also widely known that adolescence is the peak age of onset of most mental health problems," says Dr Noluthando Nematswerani, Discovery Health Head of the Centre for Clinical Excellence. "Common psychiatric disorders in adolescents include anxiety, depression, substance abuse and eating disorders. All are associated with an increased suicide risk."

Lancet commission authors add: "During adolescence, an individual acquires the physical, cognitive, emotional, social, and economic resources that are the foundation for later life health and wellbeing. These same resources define trajectories into the next generation."

"This means that what happens to our teenagers will impact their own children and so on," adds Dr Nematswerani. "That leaves us with a massive responsibility to ensure their mental and physical wellbeing, particularly in South Africa, where such a large proportion of our population is young."

Discovery Health notes worrying decline in mental health claims for children and young adults over course of pandemic

Prior to the COVID-19 pandemic, Discovery Health experienced a year-on-year (2017 to 2019) increase in medical scheme members claiming for mental health conditions in children (under 18) and young adults, at 2.2% and 6.2% respectively in children. The majority of these claims were for depression, ADHD and bipolar disorder in children. In young adults, the majority of claims were for depression and bipolar disorder.

"It is concerning that in 2020, we saw a 10.9% decrease in claims of this nature relating to children and a 5% decrease in claims relating to young adults. This is in line with a general decrease in people seeking out healthcare for non-COVID conditions over the course of the pandemic. This means that either the range of mental health conditions usually claimed for were not detected in children and young adults, or that they did not seek out treatment for them - both with serious impacts on the young people in question," says Dr Nematswerani.

50% of mental health conditions start by age 14, most undetected and untreated

World Health Organization (WHO) data shows the following:

• Depression is the fourth leading cause of illness and disability among adolescents aged 15 to 19.
• Anxiety is the ninth leading cause for adolescents aged 15 to 19 years.
• Mental health conditions account for 16% of the global burden of disease and injury in people aged 10 to 19 years.

"Perhaps the most worrying data shared by the WHO is that half of all mental health conditions start by 14 years of age but most cases go undetected and untreated," says Dr Seranne Motilal, a clinical wellness specialist at Discovery Vitality:

According to the South African Depression and Anxiety Group (SADAG), in South Africa, 9% of all teen deaths are caused by suicide. SADAG points to a major link between depression and suicide, particularly where the signs of depression are not recognised and treated. WHO data also shows that:

• Suicide is the third leading cause of death in 15- to 19-year-olds globally
• 90% of adolescent suicides take place in the world's low- or middle-income countries.

Adolescence is a uniquely tough time

Johannesburg-based trauma specialist Janine Shamos says, "Teens face many physical, emotional and social changes, all heightened by issues like exposure to bullying and violence, poverty, dysfunctional family structures, abuse and, recently, disruptions to all facets of life due to the COVID-19 pandemic."

The WHO adds these stressors to the list: a desire for greater autonomy, pressure to conform with peers, exploration of sexual identity, increased access to and use of technology, media influence and gender norms. Also, children and adolescents are especially vulnerable to sexual violence, which has a clear association with poor mental health.

"I've seen these stressors trigger new mental health issues and worsen existing ones."

Adolescents have for decades been at risk of depression, traumatic stress, and suicide. These dynamics especially affect those living in low- to middle income countries, where mental health support and treatment are often inadequate and where the impact of insecurity is more keenly felt.

Counselling psychologist Reabetsoe Buys explains, "In adolescents, protective life skills such as coping mechanisms, capacity for reasoning and emotional maturity are still developing, and this makes teens vulnerable to mental distress."

"The pandemic has worsened the stress that teens face. Many of my younger patients have struggled with the disruption to their own lives and to the world in which they function. Not only have new patients described developing mental health issues, but people with existing conditions have also noticed their symptoms worsening during this time."

Motilal adds, "A year into the pandemic, emerging evidence indicates that health, financial and social stressors have had profound impacts on mental wellbeing across the board. Children and teenagers have experienced severe disruptions- from school closures and changes in routines to isolation from peers, along with the negative impacts on their caregivers. These disruptions have put millions of young people at even greater risk of mental health distress and conditions like depression."

What are the warning signs of depression in teenagers?

• A persistent low mood - sadness and hopelessness that do not go away and where the cause is unclear
• Sleep disturbances - insomnia or too much sleep
• Changes in eating habits - eating too much or too little
• Feelings of sadness, tearfulness, emptiness or hopelessness, worthlessness, self-blame
• Angry outbursts with irritability or frustration, anxiety or agitation
• Fatigue or lack of energy
• General apathy around life and appearance
• Withdrawing socially; actively isolation from friends and family
• Decreased interest in things previously enjoyed
• Complaining of not feeling physically well, perhaps of headaches, stomach or other pain
• Problems at school, either grades affected, or teacher notices loss of focus and concentration
• General trouble thinking, concentrating, making decisions and remembering things
• Substance abuse or other risky behaviours
• Talking about self-harm, death or suicide (immediately seek professional help)

"Depression can profoundly affect areas like schoolwork and school attendance. Social withdrawal can exacerbate isolation and loneliness. At its worst, depression can lead to suicide," adds Dr Nematswerani.

How can we help young people to prevent or cope with depression?

"Part of the challenge is understanding whether a child's behaviour is typical of the complex teenage years and personalities, or a warning sign of a problem," adds Dr Motilal. "This is why parents, teachers, caregivers and loved ones all need a strong, real awareness of depression and other common mental health conditions, so that warning signs are noticed and the right steps are taken to assist."

SADAG offers these five ways to assist a depressed teenager:

1. Focus on listening, not lecturing: If you suspect that your teen is depressed, bring up your concerns in a loving, non-judgmental way. Resist any urge to criticise or pass judgment once your teenager begins to talk. The important thing is that your child is communicating.
2. Be gentle but persistent: Don't give up if they shut you out at first. Talking about depression can be very tough for teens. Even if they want to, they may have a hard time expressing what they're feeling.
3. Acknowledge their feelings: Don't try to talk your teen out of depression, even if their feelings or concerns appear silly or irrational to you.
4. Trust your gut: If your teen claims that nothing is wrong but has no explanation for what is causing the depressed behaviour, you should trust your instincts.
5. Combat social isolation: Do what you can to keep your teen connected to others. Encourage them to go out with friends or invite friends over.

Vitality at Home: a valuable, free online resource for teen mental health

"Ensuring mental health in teens is also about ensuring consistent care for our health in general," says Buys. "This means putting a good support system in place, eating healthily and exercising, sleeping well and feeding our passions, so that we are more resilient to challenges when they do come."

"Published studies and Vitality's own data show that psychological counselling and medicine, along with exercise and healthy eating, all play a huge role in preventing or managing depression and other mental illness," says Dr Motilal. "At Vitality, we are very focused on increasing awareness around mental wellbeing in people of all ages and ensuring mental illness does not go undetected. We encourage everyone to visit our free-to-use Vitality at Home website to find articles, videos, podcasts and more on everything from staying fit and eating healthily to caring for mental wellbeing at home. The website offers access to exercise sessions, recipes, breathing and mindfulness exercises, and more."

Buys adds: "Also guide your teen to suggest what they think would make them feel better and try to action these suggestions where possible. Perhaps also address specific concerns. Sleep disturbances can be tackled by limiting screen time before bed or engaging in a relaxing guided-meditation or mindfulness exercise before sleep. In this regard, Vitality at Home is a helpful tool for us all."

"It's also important to let teens know about organisations like SADAG, where they can access 24-7, free, confidential assistance on helpline 0800 456 789. In extreme cases, where a teen is having thoughts of ending their life, it's very important to get professional help from a GP or counsellor immediately."

Good mental health is key to good health

"This year, our focus needs to be on mitigating any damage to adolescents' mental health as a result of the pandemic and broader stressors experienced by young people. And, achieving that starts with acknowledging the challenge at hand," says Dr Nematswerani. "Promoting psychological well-being and supporting adolescent mental health will positively impact their potential to thrive during adolescence and into adulthood. The fact that there is no physical health without good mental health - both are fundamental to children and young people developing the resilience they need to cope with life and develop as well-rounded, healthy adults."